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APPLICATION 0R ;VER!PUMP PERMIT ?M,� <br /> . B <br /> --'SAN JOAQUIN COUNTY PU3L1C HEALTH SERVICES-- <br /> ENVIRONMENTAL H,l!ALTH DIVISION JUN 2 1 1995 <br /> P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201.388 <br /> (209) 488.3420 ENVIRONMENTAL HEA.-,,j <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES <br /> (Complete in Triplicate) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-111 S.3 AND THE STANDARDS OF ANJPAPUINCOUNTYPUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADORESS/OR APNI an wav Stockton, CA 95205 PARCEL SrZE/APN/ <br /> OWNER'S NAME — y o esno - 9DDRF55749 N.Blackstone Ave. Fresno PHONE.(209) 487-1723 <br /> CONTRACTOR Spectrum Exploration, Inc ADDRESS 2365 Wigwam Way ucr 512268 PHONE�209) 465-8712 <br /> SUBCONTRACTOR N/A „DD,ESStockton, CA 95205 ucI PHONE <br /> TYPE OF WELL/PtJMP. 21 NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING / MW-7 L 9 a] OTHER A , <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNEAIR T VAPOR EXTRACTION WELL f <br /> 'TYPE OF PUMP( 1: om^'11 P.. <br /> NRN.P. ET FIDEPTH PUMP SROST WATER LEVEL 7�. <br /> Q <br /> ❑ OUT-0F-SERVICE WELL 13GEOPHYSICAL WELL I C1SOIL BORING <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL <br /> CONSTRUCTION SPECIHCATONS A <br /> ❑ INDUSTRIAL Cl OPEN BOTTOMDIA,OF WELL EXCAVATION 8" DIA.OF CONDUCTOR CASING N/A D c <br /> C3DOMESTICMRIVATE ❑GRAVEL PAmsuETT���T+`o. 2 TYPE OF CASING/ST7_EL'PVC r 7�VOC OIA.OF WELL CASING 411 p _C. <br /> ❑ PUBLJCiMUNICIPAL ❑DRIVEN Monterey DEPTH OF GROUT SEAL 58 I SPECIFICATION Schedule 40 a <br /> ❑ IRRIGATION/AG ❑OTHER Sand GROUT SEAL INSTALLED BY :h TED-I S111=z;4 GROUT BRAND NAME Vn1(-1 a)7 E D <br /> MONITORING lT]j/-� J GROUT SEAL PUMPED:0 Ys ❑No CONCRETE PEDESTAL BY DRILLFR: 2 YL ❑Na S > <br /> APPROX.DEPTH 95' <br /> BGS LOCKING CHESTER BOX/STOVE PIPE Traf 1 _ Box S ll <br /> PROPOSED CONSTRUCTION/DMILLING METHOD: MUD ROTARY AIR ROTARY x AUGER CABLE OTHER <br /> 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 CERTIHES THE FOLLOWING:'1 CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> `HIS PERMIT IS ISSUED.I SHALL NOT EMPLOY PERSONS SUBM <br /> SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> "HE FO I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.i SHALL EMPLOY PERSONS SUBJECT TO WORKMAM'S COMPENSATION LAWS OF <br /> CAU IA.' THE t UCAMT MUST =* C <br /> E FOR ALL REQUIRED INSPECTIONS AT(20Y)ASS3A23. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> C <br /> (4//4/1 f9 s <br /> Dan <br /> PIAT PLAN(Drwr to Saalal Saw ';o <br /> 1, NAMES OF STREETS OR ROADS N O OR BOUNDING THE PROPERTY. t, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTUNE OF THE PROPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <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 /> N <br /> �1 <br /> .. <br /> .. . <br /> DEPARTMENT USE ONLY <br /> AppNCltlan Aaoeotea BY A— s3 <br /> Grtlut In.Pecoon BY Due Pump Jn P--bW BY DAL. <br /> aavVa /� rc <br /> D —1r 0- io.By Ow cC <br /> Command- <br /> IV <br /> ACCOUNTING ONLY: -D# FAC! <br /> PE CODES FEE INFO AMOUNT REMITTED CHEC (CASH RECEIVED ply DATE PBIANT/SERVICE REQUEST NUMBER INVOICE <br /> '1 FILE COPY <br />