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APPLICATION FOR WELL/PUMP PER <br /> S/OOAQUIN COUNTY PUBLIC HEALTH S ICES <br /> MI <br /> ENVIRONMENTAL HEALTH DIVISIO <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in TPlplkeb) <br /> APPLICATION IS HERE By MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOrOn INSTALL THE WOR(DESCRIBED.THIS APPLICATION 16 ADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE;CHAPTER 91115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY MmUC HEALTH SERVICES,ENVIRONMENTAL ALTH DIVISION, p <br /> 376 I n / ,c�_ oJ_ Y9v�Eaat er✓'E Sjaa <br /> JOB ADOflE6.�/OR APN/- % JLF�/ I ( P T 11 CT' v C�.G Mm PARCEL 61Z APH# 0 N (1[yn.l e P N <br /> SGbliJ" D-y Cka./t 9�e <roua✓!s s'DC^�t /yq7 ou.e/ tree Y, /.T Fr. <br /> OWNER NAMEC/p Ile /d T d /+ I F L D IN ADORE68 Fwrpr� lii%/ye ('q yYLOP-/Q)7 q E I <br /> CONTRACTOR ADDRESS <br /> n J IN;/ MIO <br /> SUBCONTRACTOR �%jP y' ��65 Wi.lwaN Dr <br /> IISqT F'�-.+-+ ADDRESS .�e.FtewY.C10 fls�oS txICS7�S/9.768MIOHE I?09-S�G,T.p>. <br /> TYPE OF WELLMUMP: IO NFW WELL ❑ REPLACEMENT WELL ® MONITORING WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J <br /> IVIA ❑New❑Ravalr H.P. DEPTH PUMP SETJL/ ". FIRST WATER LEVEL D <br /> (TYPE OF MMPI <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ SOIL BORING R <br /> ❑DESTRUCTION- <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL I❑1 /Fl OPEN BOTTOM DIA.OF WELL EXCAVATION /O DIA.OF CONDUCTOR CASING IV D <br /> LSI <br /> DOMESTIC/PRIVATE GRAVEL PACK/SIZE TYPEOFCASING/STEELAPC,ppQA yQ Vjle DIA.OF WELL CASINO Z1b D <br /> ❑ PUBUCNUNICIPAL ❑DOWN DEPTH OF GROUT SEAL S-01 SPECIFICATION R <br /> ❑ IRmGATION/AG ❑OTHER GROUT SEAL INSTALLED BY Z)F`%Ile r GROUT BRAND NAMEAitoR t cOee1 Fr e"t E <br /> ® MONITORING / BMW SEAL PIMPED: ®Yw [IN. R <br /> N. CONCRETEPEDESTALBYOLLER:l1pr Yw ❑N. 5 <br /> APPROX.DEPTH NO LOCKING CHESTER BOX/STOVEPIPE 5 <br /> PROPOSES CONSTIR IRON/dtlLUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> 1 REVERY CERTIFY THAT I HAVE PREPAMO 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 SAN MAGIAN COUNTY. HOME OWNER OR LICENSED AMNT'9 SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE W bw FOR WHICH <br /> THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUSLONTRACTING SIGNATURE CEP.TIFIES <br /> THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH Title PERMIT IS ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORXMAN'S COMPFHSATON LAWS OF <br /> CAUFOMIA.' THE APPLICANT <br /> MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 120111441041422. COMPETE DRAWING AT LOWER AREA PROVIDED. <br /> 610nM�� �A ,1��.r / TIII. y//c / /'D(F�c / /ial✓a(/r� Data <br /> la <br /> MOT <br /> MOT PLAN 1O,—to Scale)Scala •1. - <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PiOPERTY. 4. LOCATION OF"OUSE SEWAGE DISPOSAL SYSTEM On PROPOSED <br /> 2. OUTLINE OF THE PY)PERTY.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL BYBTEMS. <br /> 3. 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 WAITS. ON THE PROPERTY OR ADJOINING MXIPERTY. <br /> MRP ftQ C,i, � ct, <br /> DEPARTMENT Dale <br /> VSE ONLY <br /> Application Ace.pmd <br /> G.eut Imvecew By Dole Pvnp Inavaml.n By Dole <br /> Oe.tr,cn.n Inan n By Data <br /> C.mmant. 3 ell <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEEINFO AMOUNT REMITTED CHECKIMASN RECEIVED BY DATE P6WBT/SERVICE PEGUEST NUMBER INVOICE <br /> 3 8 <br /> /555/ <br /> Pub.Health Sew.-Enviro.173(1/97) <br />