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ATION FOR WELLJPUMP PERMIT <br /> SANg40LUIN COUNTY PUBLIC H ALTH SEPiES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 -2.(209) 468-3420 (// <br /> NOM-REFUNRpBIE PERMIT EXPIRES 1 YEAR FROM RATE ISSUED /� � <br /> (Complete In TIIpIkrtEl <br /> PLI <br /> APCATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR AND/OR INSTALL PERMIT TO CONSTRUCT AND/OINSTALL THE WORK DESCRIBED.Title APPLICATION{r�� <br /> NAL <br /> JOAQUIN COUNTY DEVELOPMENT TITLE�CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> 2 / / /J (1 /�0/s. QB. IIelf4— <br /> JOSADDRESSMIIAPNI ,' 7l0 .c)/vcol j I PNZ-L I^- CITY V�O C/C TC" PARCEL SIZE/AFNP�. <br /> Se'1LEliN9 'Dry Ge2ti)..wl bee. ,vc(a. k �3z>('Ds) /900 Two ruEll �-- e /a G/ <br /> OWNER'S NAME CA mp"ICC T. G�r0.aLCTi2•J� G�c.f �rr+rADORE66 E�i//��)� 9//609 /w,,? PHONEI <br /> CONTRACTOR ADDRESS MLRCS PHONEIF <br /> (1 e576S CUi9waw+ Dr. <br /> IF- <br /> SUB COMCTORrJpn><rcL,.-. AbbnEse Stee,E{fl.,� CA 9S,7oS ucFt57-S/ad68MIDN[Ed09-'/b-S-P7 <br /> TYPE OF WELLIPUMP: ® NEW WELL ❑ REPLACEMENT WELL ® MONITORING WELL S ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT/REPAIR ❑ VAPOR EXTRACTION WELL J <br /> 11New ElFbpdr H.P. DEPTH PIMP SET*FT <br /> FT. FIRST WATER LEVEL 0 <br /> ITYPE OF PUMPI "'777""" <br /> ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL F ❑ SOIL BORING P <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM VIA.OF WELL EXCAVATION S( q DIA.OF CONDUCTOR CASING N/A D <br /> ❑ DOMESTM/PRIVATE ®GRAVEL PACKISIZE # I/O TYPE OF CASINGISTEELR C d0lf 110 P'C DIA.OF WELL CASING .7 D <br /> ❑ PUBMMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL .3D/ SPECIFICATION R <br /> ❑ UU GATIONIAO 11OTHER GROUT SEAL INSTALLED BY �Y/IIB/ GROUT BMW NAME kle'aj1 Qe w RAIZ- E <br /> ® MONITORING GROUT SEAL PUMPED: ®Ys ❑Ne CONCRETE PEDESTAL RY DRILLER:®Vs [IN. s <br /> q <br /> APPROX.DEPTH 9O/ LOCKING CHESTER BOX/STOVE PPF Ue$ 5 <br /> PROPOSED CONSTRUCRON/DRILUNG METHOD: MUD ROTARY AIR NOTARY AUGER ( 7 CABLE OTHER <br /> I HESERY 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'B SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE MMORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IB ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SMALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CAUFORMA.- THE APPLICANT MUST CALL 31 NOUNS IN ADVANCE FOR ALL REQUIREDoaINS//PCTIONS AT UZONI SIMI COMPETE DRAWING AT LOWER AREA 1'ROIDED. <br /> Tine Dele <br /> PLOT MN!brew Re Boelel Stele le <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. e. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED <br /> B. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL BYSTEMB. <br /> J. DIMENSIONED OUTLINES 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 /> MRpftQc�► e � <br /> DEPARTMENT UBE ONLY 0 <br /> Application AeeentaA RY A.r <br /> DrouR Imoallon By Dna POInP ImPemlen By De1e <br /> De.Bm6en In.n<Bee By Dele <br /> Cemmane: F <br /> ACCOUNTING ONLY: AID/ FACT! <br /> OF 07- <br /> PIE CODES FEE INTO AMOUNT REMITTED CHECKSR:ABM RECEIVEDST' DATE PSIMSTISERVICE REQUEST NUMBER INVOICE <br /> mad 1-7 <br /> SD <br /> I <br /> Pub.Health Sew.-Enviro.173(1/97) <br />