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TYPE OF WELL <br />DOPER eorrom <br />GRAVEL PACK/SIZE \ " <br />CONSTRUCTION SPECIFICATIONS <br />OW OF WELL EXCAVATION <br />TYPE OF CASING/STERAPVC <br />DEPTH OF GROUT SEAL <br />INTENDED USE <br />CI INDUSTRIAL <br />)2( DOMESTIC/MYATT <br />1:1 PUBLIC/MUNICIPAL 0 DRIVEN <br />\-L_CiVe,C\ <br />faAymEN1 <br />IVIAR I 9 1996 <br />:6AN JOADuIN c•L;,.1.,4 <br />PLJEILIC HEALTH SO,RVICE; <br />ENVIRONMENTAL HEALTH DIVISICIr.' <br />Az.._cs‘f4t <br />, <br />APPLICATION FOR WELL/PUMP PERMIT <br />SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P.O. BOX 388.304 EAST WEBER AVENUE, STOCKTON, CA 95201-388 <br />(209) 4083420 <br />NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br />Maniples la Triplicate) <br />APPLICATION IS HEFtE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PEFUJST TO CONSTRUCT AND/OR INSTALL THE WON( DESCRIBED THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER El 1 1 1 5 .3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOE ADDRESSAOR APNS CITY PARCEL SDE/APNE <br />OWNER'S NAME \- ADDREssV1 PHONES <br />CONTRACTOR V—\.\\..\ \ ADDRESS LII Sk.AC;Att..J.,\ PHONE / <br />GLIB CONTRACTOR ADDRESS LK/ PHONE <br />TYPE OF WELUPUMP 0 NEW WELL o FEPLACEMENT WELL <br />CI WELL SYSTEM REPAIR <br />FI.P. <br />0 MONITORING WELL OTHER <br />14 IN <br />-71 Now 0 Repel, <br />1:1 CROSS-CONNECT REPAIR <br />DEPTH PUMP SETVN)Ft <br />0 VAPOR EXTRACTION WELL <br />FIRST WATER LEVEL <br />ITYOF PUMP, <br /> <br />El OUT-OF-SERVICE WELL CI GEOPHYSICAL WELL I 0 SOIL BORING ; B <br />0 DESTRUCTION- <br /> <br />DIA. OF CONDUCTOR CARING <br />ck..A <br />DIA. Of WELL CASING <br />5-1 <br />SPECIFICATION <br />CI IRRIGAT/ONIA0 0 OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME ET LI MONITORING GROUT SEAL PUMPED 0y.. 0 No CONCRETE PEDESTAL BY DRILLER:0 Yoe ON. LIS. <br />APPROX. DEPTH 'r. Z'.1 .C) ' LOCKING CHESTER BOX/STOVE PIPE <br /> <br />PROPOSED CONSTRUCTIONOPOLUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER --C, <br />I HEREBY CERTIFY THAT I HAVE FFIEPAIND THIS APPLICATION AND THAT THE WOW, WILL BE DONE IN ACCORDANCE INTTH BAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, MVO RULES AND <br />REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: I CERTIFY THAT IN THE PEFFORMANCE OF TIN WORK FOR WHICH <br />THIS PERMIT 18 ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORN1A. CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: ' I CERTIFY THAT IN THE PERFORMANCE OF 'ME WORK FOR WHICH THIS PERIATT 18 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CAUFORNIA.' THE APPUCANT MUST CALL 24 HOURS IN ADVANCE FOR AU. RESIUM DONS AT 12011140/114211. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Ellpn•el X Till. ON. <br />PLOT PLAN ICINAv to SooN) Peal. ' to <br />I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED <br />B. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT <br />STRUCTURES, INCLUDING COVETED AREAS SUCH AS PATIOS. DFOVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> <br />ApplIcoren Accepted By <br />Grout IrepootIon By <br /> <br />DootrectIon Inapaetten By <br />Comments: <br /> <br />DEPARTMENT USE ONLY <br />Aron LI <br /> 0.1. 471/A <br /> <br />Onto P.orp trope:Olen By <br /> <br />INN <br /> <br />ACCOUNTING ONLY AIDE 1 FACIF 1 <br />PE CODES ..‘Ft@R54-' AMOUNT REMITTED g• /CASH RECEIVED ST DATE PERMITMERVICE REQUEST NUMBER INVOKE J <br />: • 06D 41 'I", r -1 -, , - 14— (A) ii) , 0,-1 74- <br />almaD • <br />_