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PLICATION FOR WELL/PUMP PERMIT <br /> SANQUIN COUNTY PUBLIC HEALTH SER` :S <br /> NVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 1 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED P'� ✓�f —v�� 1 <br /> (Complat9 In T►iplie9tal <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMEN{T-TITLE,CHAPTER 9.1 115.3 SND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION.. <br /> JOB AGGRESS/OR APN/ M 1 G� Y, U PKI/N\i CfTY J 'ifs.-^� PARCEL 81ZEIAPN! <br /> GSy\ ADDRESS PHONE <br /> OWNER'S NAME �p rC <br /> CONTRACTOR ADDRESS O'V CT Vk UCl ^1cj{/i'HONE <br /> ADDRESS 1 S`-J/ '-S LjC f111L�—PHONE <br /> RVB CONTRACTOR <br /> TYPE OF WELLIPUMP. ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONRORING WELL! OTHER I�/f W l`�f Zir11 L1L, <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRA ION WE ! ✓ / <br /> ❑N.❑A11,11 H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0 <br /> HYPE OF PVMPI ❑ SOIL scruNG No R)'a <br /> (1 ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL! _ <br /> DESTRUCTION: I 1 1cl <br /> f \N <br /> A <br /> INTENDED USE TYP OF WELL CONSTRUCTION SPECIFICATIO N9� I' <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D <br /> {L D <br /> ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/etZE TYPE OF CASINO/STEELIPVC GIA.OF WELL CASINO-- <br /> ❑ PUBLIC/MUNICIPAL ❑DRIVEN ^ 1 DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ IRRIGATION/AG OTHER µ7 `►q 1 GROUT SEAL INSTALLED BY �. GROUT BRAND NAME �`mm\ E <br /> El MONITORING l Ili rr'VVV GROUT SEAL PUMPED: 11 You yq4+e CONCRETE PEDESTAL BY DRILLER:C1Y- I Ne S <br /> LOCKING CHESTER BOX/STOVE PIPE / S <br /> APPROX.DEPTH <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER_CABLE OTHER <br /> I HEgFBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND 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 WOR.FOR WHICH <br /> THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTORS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SMALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' T P I:ANT MUST CALL 24 URS IN ADVANCE FOR ALL REQUIRED INSPECTIOONGAAT("*1409-$422. <br /> COMPLETE ORAWINO AT LOWER AREA PROVIDED. <br /> 8t0.vd X Y6_yI/ PL <br /> TItI. �1 V�W1 �1 L'7 I l�U D•t. 44 <br /> ROT PLAN 01—to Sa•I6)80.1. '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.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION F SEWAGE TV'IN SAL SOF ON <br /> 3. DIMENSIONED OUTLINFS AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WDJON IMG PR PE ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH A8 PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> AP0I1c.11on Aooeeted BY <br /> Grout imoeellon BY D.te <br /> D.t. <br /> O—w.f1en Imoectlon 8Y <br /> Commr•.tc 2 <br /> ACCOUNTING ONLY: AID/ FAC! <br /> PE CODES FEE INFO AMOUNT REMITTED CH ! ASH RECEIVED BY DATE Pg"TISERVICE REQUEST NUMBER INVOICE <br /> 10 <br /> Pub.Health Sam-Enviro.173(1197) <br />