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APPLICATIQN FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX SW 344 EAST WEBER AVENUE, STOCKTON, CA WMI-Me <br /> 1209) 488.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> WompMb In TrWkstsl <br /> APPLICATION IS HERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUI,ITY DEVELOPMENT TITLE,CHAPTER 9.1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DI`ASION, <br /> ice ADDREss/ORAPNo 21480 N. Horseshoe clT„ C1ements, Ca PARCEL SREJAPTI#16 •5/bare <br /> OWNER'S NAME John Teres i _ ADDRESS P.O. Box 81 9 ,Lodi PHONE f <br /> CONTRACTO1purviance Drillers,Inc. ADDRFAV.oBox 64 ,Linden U., 377923 SNE, 887-3554 <br /> SUS CONTRACTOR n/a ADDRESS UC# PHONE+ <br /> TYPE OF WELL/PUMP• M NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL P ❑ OTHER_ <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ GROSSCONNECTREPAIR ❑ VAPOR EXTRACTION WEU-R J <br /> Z4 V 12— ®New❑Repalr H.P. 30 DEPTH PUMP SFT I A FT_ FIRST WATER LEVEL (f <br /> (TYPE OF PUMP) <br /> ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING S <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ®OPEN BOTTOM DIA.OF WELL EXCAVATION 19 FAA.OF CONDUCTOR CASING na o <br /> ❑ DDMESTICIPRIVATE ❑GRAVEL PACKISIZE^ TYPE OF CASING/STEELMVC steel DIA.OF WELL CASINO 1 2 374 Q <br /> 11PU8UC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL 'Z80 , — SPECIFICATION . 188 <br /> r+ <br /> 1@ IRRIOATION/AG ❑OTHER GROUT SEAL INSTALLED BY PDI GROUT BRAND NAME f <br /> ❑ MONITORING `1 GROUT SEAL PUMPED: [3Y. 13 No CONCRETE PEDESTAL BY DRILLER;❑Vr ❑Ne $ <br /> APPROX.DEPTH � GL `�{� LOCKING CHESTER BOX/STOVE PIPE s <br /> PROPOSED CONSTRUCTION/DRILUNO MET D: MUD ROTARY_ AIR ROTARY AUGER_ CABLE— OTHER <br /> I HMRY CERTIFY THAT I HAVE PREPARED THIS APPUCATION AND THAT THE WORK WALL BE DONE IN ACCORDANCE WITH SAN JOAOIXN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE rOLLOW1NG:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOO(FOR WHICH <br /> THIS PERMIT 18 ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WONKMANA COMPENSATION LAWS OF CAOFORNPA.- CONTRACTOR'S HIRING OR SUB-CONTRACTINO SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT W THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORT WAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' THE APPLICANT ALL 24 14DUM IN ADVANCE FOR ALL RFOl11RED INSPECTIONS AT 12411111 4MJ42i. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Signed X a Tltle Corporate Secretary Date 3/17/97 <br /> PLOT PLAN IDrrtw to SWe;Syle 'to <br /> I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. . <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED III. LOCATION OF WELLS VITHgV RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. f <br /> ` YIN <br /> 'r <br /> DEPARTMENT USE ONLY �'7 <br /> APAllaerten Acoepled BY_ • Dele _Arr 1?1 <br /> Grout Impettlon BY_ t> Do Pump Impwilon BY Dat { <br /> Deem %lpn Impeollyn BY Dille <br /> Comments: <br /> ACCOUNTING ONLY: AID# FAC# l�l-7� •'� <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# SH RECEIVED SY DATE PERMIT EST NUMBLIIR INVOICE <br /> 43 9 05 o p �� <br />