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NEW WELL <br />INSTALLATION <br />0 Now 0 Repels <br />REPLACEMENT WELL <br />0 WELL SYSTEM REPAIR <br />H.P. <br />MONITORING WELL I/ 0 OTHER <br />CROSS-CONNECT REPAIR <br /> O VAPOR EXTRACTION WELL I <br />DEPTH PUMP SET FT. FIRST WATER LEVEL 0 <br />TYPE OF WELL/PUMP: <br />(TYPE OF PUMP) <br />OUT-OF-SERVICE WELL SOIL BORING GEOPHYSICAL WELL <br />Y-242 j 1 I y ESTRUCTION: IF I (7-D 7 <br />It <br /> N, <br />2_,_,ST1) <br /> <br />ApplIcellen Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />Comments: (A.41,124.4-1Dr-' pm- TO ^Le- 61/1.- <br />2-/acir1/4 3-) <br />DEPARTMENT USE ONLY <br />Dote Pump Inspection By <br />APPLICATION FOR WELL/PUMP PERMI1 <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br />(209) 468-3420 <br />NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete In TrKteete) <br />APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY Font PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />—0,20111 Aro Ade-- crry5-10 c-1Z-411•1 C (51... PARCEL SIZE/APNI .3 -X; AL <br />OWNER'S NAM <br />k \Welt D ADDRESS a324 fAsf- c---6.611-4-arc; 37/54o PHONE <br />Pt.) <br /> <br />i- •5(.)63 <br />5. O.. emie N <br />JOB ADORE S A 8 OR <br />JOAAIN COUNTY DE LOPMrT TITLE. CHAPT4FelLag- 11,1 V,ttL T E STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION <br />*te--etta-el .he ADDRESS -70 / Al • itiVd.ij ST" PHONE 93 7o a 5 <br /> <br />SUB CONTRACTOR ADDRESS Lief PHONE <br />INTENDED USE <br />INDUSTRIAL <br />o <br />• DOMESTICMRIVATE <br />PUBLIC/MUNICIPAL <br />IRRIGATION/AG <br />MONITORING <br />APPROX. DEPTH <br />TYPE OF WELL <br />0 OPEN BOTTOM <br />El GRAVEL PACK/SIZE <br />o DRIVEN <br />0 OTHER <br />rec—F <br />PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY <br />CONSTRUCTION SPECIFICATIONS". <br />DIA. OF WELL EXCAVATION Go me A <br />TYPE OF CASING/STEEIJPVC ( <br />DEPTH OF onour SEAL el) <br />GROUT SEAL INSTALLED BY r e-J <br />GROUT SEAL PUMPED: 0 Yes 0 No <br />LOCKING CHESTER BOX/STOVE PIPE <br /> AIR ROTARY AUGER CABLE X OTHER <br />A <br />& p i <br />GROUTBRAND NAME <br />CONCRETE PEDESTAL BY DRILLER: 0Y.. O N. <br />NA. OF CONDUCTOR CASING <br />NA. OF WELL CASING 67 .0/ xt <br />SPECIFICATION <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 BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WOES( FOR WHICH <br />THIS PERMIT IS ISSU Cr, I SHALL NOT NS SUB CT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA. CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: CE IFY TH N T RFOR A 0 THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." T E FOR ALL REQUIRED INSPECTIONS AT 1204) 4414423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Signed X X Title 01/4•11/1(.\-- Delo 722 <br />PLOT PLAN fOrrms to Scale) ScsIe <br />I. NAMES OF STREETS OR ROADS NEAREST TO on BOUNDING THE PROPERTY. <br />OUTLINE OF THE PROPERTY. 'GIVING DIMENSIONS AND NORTH DIRECTION. <br />DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. <br />to <br />4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM on PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />ACCOUNTING ONLY: AIDE FACE <br />PE CODES FEE INFO AMOUNT REMITTED CHESK,aASH RECEIVED IV OAT- PERMIT/SERVICE REQUEST NUMBER INVOICE <br />...• ...- .$) <br />t, -.) A <br />SYMFROF <br />(r3 7 ..3 I t,f i ...c C) q • <br />Pub. Health Serv. - Enviro. 173 (1/97)