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JOB ADDRESS/OR APNF I I CiL, e_ CITY pi 4 PARCEL SIZE/APN/ <br />CONTRACTOR , -e <br />NEW WELL <br />INSTALLATION <br />Now 0 Repair <br />OWNER'S NAME , 5_13.1 s • <br />, • / <br />ADDRESS ( 4 J <br />if LI <br /> <br />ADDRESS pi r, LEI <br />9 z• <br /> <br />ADDRESS ki-nre1-.^ 2 , .4 cps' <br />- PHONE •V-7 - Z:5-C-C=1) <br />:A ucs „,)/(1 PHONE # -5'f <br />UCF 1""k% 5 1 1. "5-- PRONE 5PC-10 <br />0 OTHER <br />El CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELL 0 <br />DEPTH PUMP SET FT. FIRST WATER LEVEL cr- <br />OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELLS 0 son. BORING <br />(TYPE OF PUMP) <br />0 DESTRUCTION: <br />INTENDED USE <br />El INDUSTRIAL <br />DOMESTIC/PRIVATE <br />PUBUC/MUNICIPAL <br />IRRIGATION/AG <br />MONITORING <br />APPROX. DEPTH <br />CONSTRUCTION SPECIFICATIONS A <br />0 OPEN BOTTOM DIA. OF WELL EXCAVATION <br />IQ GRAVEL PACK/SIZE alL 3„....._ TYPE OF CASING/STEEUPVC <br />0 DRIVEN DEPTH OF GROUT SEAL <br />0 OTHER GROUT SEAL INSTALLED BY <br />GROUT SEAL PUMPED: glYoo*To <br />LOCKING CHESTER SOX/STOVE PIPE i UX <br />AIR ROTARY AUGER CABLE OTHER <br />TYPE OF WELL/PUMP: <br />' SUB CONTRACTOR , , <br />REPLACEMENT WELL <br />WELL SYSTEM REPAIR <br />H.P. <br />0 MONITORING WELL I - <br />TYPE OF WELL <br />(1.• DIA. OF CONDUCTOR CASING 144- <br /> DIA. OF WELL CASING <br />SPECIFICATION <br />(GROUT BRAND NAME <br />CONCRETE PEDESTAL BY DRILLER: Rt Yee ON. <br />PROPOSED CONSTRUCTION/DRILUNG METHOD: MUD ROTARY <br />Application Accepted By t/tirtztA, \C-PV"V <br />Grout Impaction By L'ICIJAAGA Date fr. <br />Iloatroction Impaction By <br />DEPARTMENT USE ONLY <br />Pump Inspection By <br />Dots 7/3e/f21 <br />Dela <br />Area <br /> II <br />Comment•• <br />ACCOUNTING ONLY: AIDS FAC/ <br />..._.„ <br />PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECEIVED BY DAT _.,.----- <br />..---- <br />PERMIT/SERVICE REQUEST NUMBER INVOICE <br />3 , 01 .01,00 3370 * /, Sr( A .- o 081 3 -/ , <br />----------_________ <br />Pub Health Serv. - Enviro. 173 (1/97) <br />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-REFUNDARE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Dimpled. In Tr',Mental <br />APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />JOAOUIN COUNTY DEVELOPMENT TITLE. CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES. STATE LAWS, AND RULES AND <br />REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR UCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br />THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA. CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES r <br />THE FOLLOWING: • I CERTIFY THAT IN THE PERFORMANCE OF THE WORC FOR WHICH THIS PERMIT IS ISSUED. I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF V <br />CALIFORNIA.' THE APPLICANT MUST CALL 24 ROLSIS,IN ADVANCE FOR ALL REGUIRED INSPECTIONS AT 12011 4511.11423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Signed X (N. TRIto P,cc, <br /> <br />PLOT PLAN (Mow to Scale) Scale <br />I. NAMES OF STREETS OR ROADS NEAREST TO on BOUNDING THE PROPERTY. <br />2. OUTLINE OF THE PROPERTY. GIVING DIMENSIONS AND NORTH DIRECTION. <br />1. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. <br />4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />to