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4 ,'PLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SER, ,ES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3426 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICompMte iR T.r4&ml@I. <br /> APPLICATION IB HERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR'INSTALL THE WORT(DESCRIBED.THIS APPUCATKIN 18 MADE IN COMPLIANCE WffH SAN <br /> JOAGUIN COUNTY OEVELOP'MENT TITLE,CHAPTER 9-1115.3 AND THE�STANDAF 09 OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, /� /'� <br /> JOB ADOREBS/OR APNI `,' �C� �-+T �1/� - CITY S' '�rL_�_ f ��_ PARCEL SILEIAPNE OF2-40&1—/ <br /> OWNER'S NAME 0 S c- +��e �L�y ADDRESS r.0 L?tom-'^ L ry1f�Wk <br /> PHONE+/ 7 <br /> CONTRACTOR C C'V f -IC yLr CT{I L ADDRESS �.lJ��c_- CA40A•C'f WkC/•-,,�•PHONE R <br /> sue CONTRACTOR ADDRESS UCS PHONE <br /> TYPE OF WELL/PUMP; ❑ NEW WELL . LU49PLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER <br /> ❑ <br /> INTALLTI ❑ WELL SYSTREPAIR 11CROSS-CONNECTREPAIR ❑ VAPOR EXTRACTION WELL S 1 <br /> O L1V ONMZ, <br /> t <br /> m.p. 30 DEPTH PUMP SET FT. FIRST WATER LEVEL __ O <br /> (TYPE OF PUMP) ❑ OUT,OF•DERvrcE WELL © GEOMIY6ICAL WELL/ ❑ FOIL SWUNG B <br /> Y <br /> ❑DESTRUCTION: <br /> IRTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL 1�-!1-,OPEN BDTTOM / DIA.OF WELL EXCAVATION 2-2-1-1 _ DIA.OF CONDUCTOR CARMC D <br /> ❑ bOM£9TICtMVATE 4c'ORAVEL PACKIRIZE TYPE OF CASINO/DTEELMVC fl [C'C DIA.OF WELL CASINO " D <br /> ❑�/�PU^BLICIMUNICIPAL ❑OMVEN - DEPT"OF GROUT BEAL sy I�y/� SPECIFICATION.!_�rt.. .CVC R <br /> C IRRKIATIONIAO 13 OTHER GROUT DEAL INSTALLED BY CL4 �4^ GROUT BRAND NAMEE <br /> �rS�L�T/-ry_4LT <br /> ❑ MONITORING GROUT BEAL PUMPED: Ll-',-. ❑No CONCRETE PEDESTAL BY DRILLER;04104 [-']No S <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S <br /> PROPOSED CONSTRUCTIONIDRILLINO METHOD: MUD ROTARY AIR ROTARY AVOER CABLE OTHER L� <br /> r 20TAr <br /> I HE9EBY CERTIFY THAT 1 HAVE PREPARED THIS APPtJCATtON AND THAT THE WORK WILL.SE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REOULATION9 OF THE DAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH - <br /> THIS PERMIT IS ISSUED,1 0IIALL NOT EMPLOY PERSONS BU13JECT TO WORKMAN'$COMPI NSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB•CONTRACTINO SIGNATURE CERTIFIEB <br /> THE FOLLOWING: '1 CERTInrIN6TEPERFORMANCE Of THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSON$SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CAUFORTDA.' T A C4 HodLpq!11AOVANCE FOR ALL REOIIIRED INSPECTIONS AT 12081844428. COMPL.ERE DRAWING AT LOWER AREA r'FIOVIDEO. <br /> �� �'�^-•J TIUs�//� <br /> PLOT PLAN I[Now 1.SwAal Se*I& 'to <br /> 1. NAMED OF RTRE£f9 OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PIOPIISEO <br /> 7. OUTLINE OF THE P"OPERIY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE D18POSAL SYSTEMS. ' <br /> 3. DIMENSIONED OUTLINER AND LOCATION OF ALL EXISTING AND PROPOSED 11. LOCATION OF WELL@ WTFHIN RADIUS OF ONE HUNOHrO TIrTY rT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> ., ..,...:...., q .. .. f j <br /> V <br /> ti..... <br /> : <br /> -R ... <br /> CA <br /> �.. ;�. ... .... ..:: . .. <br /> �p,YM . <br /> . , .. .. ' . <br /> SUN . .�.ti9.7. ... : <br /> PURI`C,4':.A,. :, .r I'111 11 io <br /> DEPARTMENT USE ONLY (/,' <br /> AppRa�1en A...ptad By D.le v I --7 MMll:�- <br /> TialR huaeelhn,By- - -'-Date _ p I.&Peb11a 0y bete,/' <br /> E, =� <br /> Onew.118.Inp"llon By Dote <br /> C.-.,te: a I'V LN+ ri�oC,P <br /> u ed 6 sefs � � raw ea ! ` c.75 in W q <br /> / <br /> ACCOUNTING ONLY: AIDS FACS <br /> PE CODES FEE INFO AMOUNT REMITTED CHEC ICA@If RECEIVED BY DATE P61MIT!@ERVICE REQUEST NUM801 INVOICE <br /> �S b0 <br /> Pub.Health Serv.-Enviro.173(1197) <br />