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PPLICATION FOR WELL/PUMP PER <br /> SAMMOAQUIN COUNTY PUBLIC HEALTH S ICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUER <br /> (Complete In TrlplkElol <br /> APPLICATION IB HERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WRIT BAN <br /> JOAQUIN COUNTY DEVELOPMENT TrMJ!,CHAPTER 5-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB AODRESSMR APNI DO / - f 6 D -O3 CT' GL�M�{.v 7:.T• <br /> �������p��.����yy,� �,PARCEL BIZE/APNI <br /> OWNER'S NAME "rrr/W P ADDRESS 322-52- VAWA. Tr nWy/ uNjo/j (.1� PHONE( sl 87F- <br /> CONTRACTOR VWY`W cft" .�d��/ We- ' AVINESS 30S 2NPSr ST. ft SUCS 9'107 RIONE I (1Pl -~y1:'��T9A— <br /> SUBCONTRACTOR PIl'CP-RE L DRN-L.NJ SN LO. ADDRESS P'O• OVX 9034Z PALO Ad'�I 2tP'j;Oy&F PPHONEI B <br /> TYPE OF WELVPIMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I MOTHER Pia=P1RY;'M (2-11 <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS CONNECT REPAIR ❑ VAPOR EXTRACTION WELL F ,/ <br /> R VFE OF PUMP( ❑New❑RoPaIr N.P. DEPTH PIMP SET FT. FIRST WATER LEVEL p <br /> qma <br /> 11OUT-0E-SERVICEWELL 11 GEOPHYSICAL WELL I 11 SOIL BORING D <br /> ❑DESTRUCTION-. Prpg" y, TO ESE-lAV A,{.L,.E,p W 01OW= E Av ✓E1- a6VTeC+I.Nl4A:1.- -CAMPL-044 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ' MPLA�1 A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM VIA.OF WELL EXCAVATION 57/89 DIA.OF CONDUCTOR CASINO D <br /> ❑ <br /> DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEP/PVC PVL DIA.OF WELL CASINGp <br /> ❑ PUBLICRAUNICIPAL ❑Iq�DRIVEN DEPTH OF GROUT SEAL N� SPECIFICATION N$J$Ad.ID TrTA✓E�Alyt <br /> ❑ IRRIGATION/AG KOTHER CFlezc►A�.ssfc� GROUT SEAL INSTALLED BY P17C4teg- BMW BRAND NAME E <br /> MONITORING / GROUT REAL PUMPED:ox. ❑N. CONCRETE PEDESTAL RY DRILLER:❑V. [IN. 5 <br /> APPROX.DEPTH .7✓ LOCKING CHESTER BOX/STOVE RPE S'�11� PIPE_ S <br /> PROPOSED CONATRUCTIONIdeLDNG METHOD: MUD ROTARY X AIR ROTARY AUGER CABLE OTHER <br /> *AcR.A. D6LAO-ev PSC04P7W1I Pf - PIS—IWC FIS ZE£awv-M*('M"i- W**--PAA <br /> I HEMBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CEIRIFIES THE POLLOWING:'I CERTIFY THAT N THE PERFORMANCE OF THE WOR(FOR WHICH <br /> THIS PERMIT IS ISSUED,I SMALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN-8 COMPENBAT10N"We OF CALIFORNIA.- CONTRACTOR'S HIRING OR SU"ONR1ACTING SIGNATURE CERTIFRB <br /> THE FOLLOWING: ' CERTIFY] A IN THE PERFORMANCE OF THE WORK FOR LMIICH THIS PERMIT IS ISSUED,1 BNALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CAUFORNIA. A UCAI f MU LL fA HOMB IN ADVANCE FOR ALL REQUIRED INSRCHONSrAT��IZOeI ABB�ef2. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> BIBn.J X TRI. � .)_►� f-'G n D.ta 4/14/97 <br /> ROT PLAN Ph.W SO.1.1 SON. 'I. <br /> 1. NAMES OF STREETS ADS NEAREST TO OR BOUNDING THE PROPERTY. S. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR McrV ED <br /> 2. OUTLINE OF THE PRD PTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> D. DIMENSIONED OUTLNES AND LOCATION OF ALL EXISTING AND PROPOSED S. 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 /> Ti9le- LO�k�45141.. OF 6raE-['�Ce.E�/P1�9oM�GEFZ. 2-II, PL�k9E- s� FIEL4RE. 1 <br /> A�.cHE'-p 'C� 6�EtrGEcy{JIcAt_ �cPLFR+0.��1 +nbK-K. PLAN. <br /> A DEPARTMENT USE ONLY <br />