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*APPLICATION FOR WELL/PUMP PERMIT m e- Lsa UA 2z I�Z <br /> '�.C,aA SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> r, LCA q5?-6-Z- 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209)468-3420 <br /> NUN-RETUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �7 4 a- <br /> IC'mpi@le In Tr}Reet/I l I 1 71 / I <br /> Cl <br /> L=AOU(N <br /> LICATION I8 HEM 0Y MADE TO THE SAN JOAOUIN COUNTY FOq A PER.IIT TO CONSTRUCT ANDMn INSTALL THE WOR(DESCRIBED.TB8 APPLICATION M MADE W COM ANCE WITH SAN <br /> COUNTYOEVELOPIM�EM� INTLE,CHAAPPTER 9-1119.3 AND THE STANDARDS OFSAN JOACUINCOUNTYPUBLIC HEALTH SERVICER,ENVIRONMENTAL HEALTH OM N. <br /> ADDRESSMA APNS !L 0 � p 0 d- tj I,.J,Q�1G.. a,,• ., CITY I�+CK 1 - N1. PARCEL IHMA <br /> ER' <br /> 'NAME N•LJAI -be�TR Gn <br /> R-rE4.I"l Try(t{AIe,ES� �,�984 ofD o (.ei,tmga/s�.❑O�i <br /> CONTRACTOR C Re G G DR I LLI AIG ADDRESS ISo �Dw e St, t!�FII�Th�6-5-6'i0q 9zs S _5%00 <br /> .>Al S GL r/d'AIT PHONE 13-1 <br /> 11`N ADDRESS L92a OLL Q±g- 94P CS P-NCO 2-4-ZLod <br /> 9L5 <br /> TYPE OF WELVRIMP ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL/ ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS{ONNECTREPAIR ❑ VAPOR EXTRACTION'WELL! J <br /> DYPE OF PUMP) <br /> 11N.11PS * H.P. DEPTH PUMP SE— EVEL FT. FIRST WATER L 0 <br /> 8_ 11 ❑y OVT�-0P-6EAVKE WELL ❑ GEOPHYSICAL WELLN <br /> ♦ BOIL BORING <br /> ElDEBPRIIITI <br /> CON&141X S� S � IA (¢Q�O� (�� �L.(� �Q�yy�.�.� �(� A V �I"•���A� <br /> INTEMOED USE TYpE OF WELL C CONSTRUCTION SPECIFICATIONS Ali A <br /> J� 11 INDUSTRIAL 11 OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D <br /> ❑ DOMESTICIP'VATE ❑GRAVEL PACX/8RE TYPE OF CASINOATEEINVC INA.OF WELL CASINO D <br /> ❑ PUBUCMUNICNAL ❑DRIVEN DEPTH OF GROUT BEAL SPECIFICATION 4 <br /> ❑ MIOATION/AG ❑OTHER GROUT SEK INSTALLED BY GROW BRAND NAME E <br /> ❑ MONROmHG GROUT SEAL PIMPED: ❑Ys ❑Ne CONCRETE PEDESTALBY DRRIFR:❑YM ❑I% S <br /> APPROX.DEPTH LOCKING CHESTER SOXMTOVE PPE S <br /> MOMXM CONSTAUCTONID18WN0 METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> 1 HE^ BY CERTIFY THAT I IIAVE FAEPAREO THIS APPICAHON ANO TWAT THF WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE BAN JOAOUIN COUNTY. HOME OWNER OR LIOEN8ED AGENT'S SIGNATURE CERTIFIES THE FULLO MINO:•1 CERTIFY THAT IN THE PEFFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMITM ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORMMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR''HIRING On SUB-COWRACTING SIGNATURE CERTIFRS <br /> THE FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORWAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.- THE APPiCANT UUJT CALL 224�MUFM IN ADVANCL FOR ALL REQUIRED INSPECTIONS AT uWAl 4tl44� 223. COMPLETE DRAWING AT LOWER AMA PRO DED. <br /> massa X-------'— - 1• no. <br /> 1 <br /> OT PAN IOT..v le @a.lel BeeN •to <br /> 1. NAMES OF STREETS OR FOADS NEAREST TO I'M BOLT INT THE ROPRTY. 4. LOCATION OF MUSE SEWAGE DISPOSAL SYSTEM On pMOPOBFO <br /> 2. OUTLINE OF THE PROPERTY,GMNO DIMENSIONS MONTH DIFECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEM@. <br /> 3. DIMENSIONED OUTLMF.S AND LOCATION OF All EXISTING AND PROPOSED S. LOCATION OF WIELLS WITHIN RADIUS OF ONE HUNDRED FBTY FT. <br /> STRUCTURES,INCLUDING COVEPEO AREAE SUCH AS PATICS,MB AYS,AND WALKS. ON THE PROPERTY OR ADJOINING PnOPEHTY. <br /> �6 �-�-�: ���' <br /> A <br /> s�: i <br /> EPMTMFMT Vte ONLY <br /> APWI.eDen Ams tW BY <br /> bR hd' <br /> a.eM I,wPeatlen Br Dne Ptm I ;'_• <br /> P naveetlen BYbete <br /> Denrwlbn Immsvflen BY Osle <br /> cee,Rl«M.: 1'A <br /> ACCOUNTING ONLY: AID/ FACS <br /> pE CODES FEE INFO AMOUNT AEMITTM CHECX/ICASH RECEIVED BY DATEPEI@WIT/SERVICE ME9 VEST NUMRG1 INVOICE <br /> 0IM0 0 7 4 rh10 oq <br /> Pub.Health So".-Enviro.173(1/97) <br />