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TkN JOAQUIN COUNTY PUBLIC HEALTH SERVICES` <br /> ENVIRONMENTAL HEALTH DIVISION <br /> TP.O.BOX 388,446 N.SAN JOAQUIN ST.,STOCKTON,CA 96201-388 <br /> (209)468-3420 <br /> N®V 2 419%N-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made todhelSan Jo ill ty for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County DevelopNta ' 9�i�d the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> Job Address/or APH# Z 3 O Ujes+ Wish I�� 1� �� City i v G(f�'{—p L, Parcel Size/APH# <br /> Owner's Name r�(Z T �Z�C(��� Address �t Phone# <br /> Contractor <br /> S L J"�� SGL. �Z OUf' Address 4l I( W I AJ !,2LIa— i D 1-4 LU.S hone# (Ltb_T <br /> Sub Contractor W Vy (.(�P5}�� � LL(/V Address SI �� Lic# 7 hone# 7L)7 <br /> 6 <br /> TYPE OF WELUPUMP: [J NEW WELL []REPLACEMENT WELL []MONITORING WELL#2.3A []Other <br /> *ESTRUCTION []OUT-OF-SERVICE WELL (]GEOPHYSICAL WELL# p SOIL BORING <br /> []INSTALLATION []WELL SYSTEM REPAIR []CROSS-CONNECT REPAIR (j VAPOR EXTRACTION WELL# <br /> []New []Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIOfNS <br /> []INDUSTRIAL []OPEN BOTTOM DIA.OF WELL EXCAVATION t? I bt DIA.OF CONDUCTOR CASING z f^� <br /> [J DOMESTIC/PRIVATE []GRAVEL PACK SIZE TYPE OF CASING/STEEUPVC p✓C DIA.OF WELL CASING Ln1 G44 <br /> []PUBLIC MUNICIPAL []DRIVEN DEPTH OF GROUT SEAL s-F" ___S SPECIFICATION <br /> []IRRIGATION/AG (]OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> []MONITORING GROUT SEAL PUMPED: es []No CONCRETE PEDESTAL BY DRILLER. Yes [] No <br /> APPROX.DEPTH LOCKING CHESTER BO STOVE PIPE FOX- <br /> PROPOSED CONSTRUCTION/DRILLING METHOD:MUD ROTARY AIR ROTARY_AUGER ABLE_OTHER_ <br /> I hereby 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's signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is 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 certifiy that in the performance of the work for which this permit is issued,I shall employ persons subject to WORKMAN'S COMPENSATION Laws of <br /> California." THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT(209)488-3423. Complete drawing at lower area <br /> provided. <br /> Signed X �17Title <br /> PLOT PLAN(Draw to Scale)Scale—11 to <br /> 1. Names of streets or roads nearest to or bounding the property. 4. Location of house sewage disposal system or <br /> 2. Outline of the property,giving dimensions and North direction. proposed expansion of sewage disposal systems. <br /> 3. Dimensioned outlines and locations of all existing and proposed 5. Location of wells within radius of 150 ft.on <br /> structures,including covered areas such as patios,driveways, the property or adjoining property. <br /> and walks. <br /> WN Tp <br /> 0 <br /> Nu <br /> E <br /> k <br /> DEPARTMENT USE ONLY <br /> Application Accepted By i Date /Z d Area Btu <br /> Grout Inspection By •' Pump ins <br /> pwecltio�By J Date <br /> L4WComments: <br /> Destruction Inspection By CL(/C <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> �a2 <br /> 09IR7v <br />