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APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complefs In TRfplkBul <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 WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> 214 0 9 Flood Rd. ,Linden JOB ADORE99/OR A{71# PARCEL 912E/APIP/ <br /> OWNEn'SNAME Melvin & Anthony Gondolfo ADDRESS 20516 Flood Rd. ,Linden MIONE# <br /> CONTRACTOR Purviance Drillers , Inc . ADDRESPOB 64 , Linden LIQ, 377923 PGNE,887-3554 <br /> BUB CONTRACTOR ADDRESS UC# PHONE# <br /> TYPE OF WELLMUMP; ❑ NEW WELL ❑ REPLACEMENT WELL ITORINO WELL# ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR L,(1j CS089-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ J <br /> ❑New❑R.P., H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> (TYPE OF PVMPI <br /> ❑ OUT-OF-SERVICE WELL ❑ OEOPHYSICAL WELL# ❑ BOIL BORING R <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D <br /> ❑ DOMESTICR'NVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEEtMVC DIA.OF WELL CASINO D <br /> ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ IRRIOATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITORING OROUT SEAL PUMPED: ❑Yee [IN. CONCRETE PEDESTAL BY DRILLER:❑Yee ❑Ne 5 <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE 5 <br /> PROPOSED CONSTRUCTIONMNLUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AN <br /> SEOULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT 18188VED,1 91HALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWINO: '1 CERTIFY THATPT TTPF <br /> RFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WOAKMAN'S COMPENSATION LAWS OF <br /> CAUFO T PPUCANT MVS CALL 24 URS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT("01401114423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Slanod X Tltl. Corporate Secretary 0i1. 1 /10/0 0 <br /> PLOT PLAN(Dr—to 8-1.1 Re.l. 'to <br /> 1. NAMES OF STREET@ OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL 8Y9TEM On PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,OIVMp DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAOE DISPOSAL BYBTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION LLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAB SUCH A8 PATIOS,DRIVEWAYS,AND WALKS. 1 PERTY OR ADJOINMO PROPERTY. <br /> t_ <br /> ... <br /> i............i. .. _ ......_ V <br /> .. i <br /> U <br /> PLVwp o <br /> .. . . :. ........ .: . . <br /> :... . .. :.::::.::. <br /> DEPARTMENT VSE ONLY <br /> C <br /> AVPllo.tlon A—mted By Det. V L1 Ar ee <br /> 0—A IMyeolbn BY Oae Pur*+o In.peetlon y <br /> Dn.lnrctlen Imneelbn By <br /> Tj <br /> C—or'w <br /> ACCOUNTING ONLY: AID# FACR <br /> PE CODES FEE INFO AMOUNT REMITTED CHEC !MAIN RECEIVED BY DATE PEPIMIT/SERVICE REQUEST NUMBER INVOICE <br />