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APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NDN-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICempwN In T►IpRoathl <br /> APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.TIIIS APPLICATION 18 MADE IN COMPLIANCE Wr7H SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE[STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEA`L_TH1 SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADORE <br /> SS/OR APN, i 71,; ,[r�rT�l rf - j-T l'-(X:/ CITYI VG K-(l.�'v I pp PARCEL S12FJAPN, <br /> OWNER'S NAME.04 ✓I - V6? h ka ADDRESS Et", 1,-4" <br /> ADDRE � 4G uccoNTRAcroR UNteC �L41 �i / <br /> Uy <br /> PUB CONTRACTOR_.� ?n/ �}I.yI .�VIL ADDRESS F'U X51 !%iG "14/G��I' UCI <br /> TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONfTORINO WELL, ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL, J <br /> ❑New❑Papal, H.P, DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> IT YPE OF PUMPI <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL, SOIL BORING S <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONStt A <br /> y <br /> ❑ INDUSTRIAL ❑OPEN noTTOM DIA.OF WELL EXCAVATION 1 I L] DIA.OF CONDUCTOR CASINO 0 <br /> ❑ DOMESTICR9VVATE ❑GRAVEL PACK/SIZE TYPE OF CA91NG/9TEEL/PVC P7- DIA.OF WELL CASINO A//,' O <br /> 11PUBLIC/MUNICIPAL �❑yy DIOVEN 1 DEPTH OF GROUT SEAL / 2LT. SPECIFICATION --�- R <br /> ❑ IRRIGATION/AG EIOTHER NIA GROUT SEAL INSTALLED BY TIQ'of"e- GROUT BRAND NAME +" •Yt(d 4•*T'I+�Z' E <br /> ❑ MONITORING j GROUT SEAL PUMPED: ❑Yee gv- CONCRETE PEDESTAL BY DRILLER:❑Yee ;RN. S <br /> APPROX.DEPTH �"'l I LOCKING CHESTER BOX/STOVE PIPE S <br /> PROPOSED CONSTRUCTIONRMSLLINO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> 1 HE-EBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,LAND RULES AND <br /> REGULATIONS OF THE BAN JOAQUIN 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 18 ISSUED,181/ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALWORMA.- CONTRACTOR-8 HIRING OR SU"ONTRACTMO SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I ETAIFY THAT PN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORK]MAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' THE CANT MUST CALL 2+HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12001 SM-7/4�_2r2. COMPLETE DRAWING AT LOWER AREA PROVIDED.ne <br /> 810d X W Tltle ��•D JI-Ii- LT e O 107L L Date :` �+J <br /> 3 —�— [ 7 <br /> PLOT PLAN(Ovew to Sahel Boole 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVn4G DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> J. DIMENSIONED OUTLINFS AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WTTHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINM PROPERTY. <br /> 1 <br /> /�✓� DEPARTMENT USE ONLY G <br /> Applleetten Aeeept -3 ed By ( `� t�� Dole I ( - 1-7 A— 0 <br /> i <br /> Grout Inepeatlen By vete P-0 Inepectlen By Date <br /> Drbuatten Imp—tion By Data <br /> C—ft'tet <br /> ACCOUNTING ONLY: AID, FACT <br /> PE CODES FEE INFO AMOUNT REMITTED ". /CAN" RECEIVED BY DATE PERMIT/SERVVICE REQUEST NUMBER INVOICE <br /> Pub Health Serv.-Enviro.173(1/97) <br />