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DO s ads <br /> dOsa�� <br /> APPLICATION FOR WELLJPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION �r L <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 1 - <br /> (209) 468-3420 4-1 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) <br /> APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WRIT SAN <br /> JOAQUIN COUNTY DEVE//l/�PMENT TITLE,CHAPTER 8-1 11 6.3 T <br /> D HE TANDAROS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADORE 99/OR APN/ PARCEL SIZE/APN/ <br /> OWNER'S NAME AO REAS PHONE F <br /> CONTRACTOR A AOTNIEBS UCI <br /> AVB CONTRACTOR ADDRESS UC! PHONE <br /> TYPE OF WELLMUMP; 04 NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL F J <br /> ❑Na­❑Repeh H.P. _ DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> !TYPE OF PUMPI <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL• ❑ SOIL BORINO S <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE O CONSTRUCTION 6PECIFICATIONt A A <br /> ❑ INDUSTRIAL OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO r� O <br /> ❑ OOMFSIICI•RIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEELIPVC DIA.OF WELL CASINO yl/ O <br /> E❑ PUBLIC/MUNICIPAL ❑DRIVEN 4'-� DEPTH OF GROUT SEAL , SPECIFICATION R <br /> 11{�RRIOATION/AO ❑OTHER V GROUT SEAL INSTALLED BY GROUT BRAND NAME 624 E <br /> ❑ MONITORING ' GROUT SEAL PUMPED: ❑Yas a CONCRETE PEDESTAL BY LLER:❑Y« ❑No S <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE / S <br /> PROPOSED CONSTRL/CTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE V/ OTHER <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPl1CATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REOULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF T14E WORK FOR WHICH <br /> I HIS PERMIT 18 ISSUED,1 814ALL NOT EMPLOY PER S SUBJECT TO WORKMAN't COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: '1 CERTIFY THAT IN THE PE ANCE OF THE WOW FOR WHICH THIS PERM r IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN't COMP"SAT10N LAWS OF <br /> CAUFORNIA.- THE#qUCANT MUt CALL 21 1 OVANCE FOR ALL REQUIRED INS NS AT,2 I I41130-3/23. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Blened X Title xle Data <br /> PLOT PLAN ow to Soelel Soels to <br /> I. NAMES WsTnEcTs OR ROAOB NEAREST TO OR BOUNDING THE PERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,OIVINO DIMENSIONS AND NORTH DIRECTION. EXPAN91ON OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED e. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> ` :_.. <br /> I <br /> 'W' u <br /> APR 11999 <br /> SAei,iOAQUI.N WON`T <br /> PU811 HEALTH SEF`R/ICES <br /> I,,viRQNY�fNTI�I HEP <br /> [IhriSl< <br /> , <br /> DEPARTMENT USE ONLY <br /> Applloetle Aooepted By <br /> Dole r Mw <br /> O—A Ir»pee tion By Dote G �CJ / P)Gnp Impectl—By �D/ Del• / <br /> Deet.ttetl—I—pool n By DNe <br /> Cem 'w <br /> ACCOUNIIHO ONLY: AID/ FACS <br /> PE CODE$ FEE INFO AMOUNT REMITTED CHECKI/CA$11 RECEIVED Sy DATE P91MIT/SERVICE REQUEST NUMBER INVOICE <br /> 43.7 /g�1 i � p 7 r3lt 1 `t-09 0 1 <br /> CA •li5oQSo 50 <br /> D,,h I-Innith Cury -P­i­ 171 11/Q71 <br />