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(TYPE OF PUMPI <br />o NEW WEU_ <br />0 INSTALLATION <br />0 Now 0 RoolOr <br />TYPE OF WELL/PUMP: <br />0 DESTRUCT/ON: <br />REPLACEMENT WEIL <br />0 WELL SYSTEM REPAIR <br />H.P. <br />OUT-OF-SERVICE WELL <br />CROSS-CONNECT REPAIR <br />DEPTH PUMP SET FT. <br />GEOPHYSICAL WELL S <br />MON/TORINO WELL OTHER <br />VAPOR EXTRACT/ON WELL I <br />FIRST WATER LEVEL <br />ISKSOIL BORING <br />OTHER 2)97." PROPOSED CONSTRUCTION/DIELUPIO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE <br />otaktit <br />DEPARTMENT USE ONLY <br />AoollootIoro Aosoot o4 Doto 7 <br />IliPPLICATION FOR WELL./PUMP PER4 <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br />(209) 468-3420 <br />ROPUREFUNDARLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete hi Trfplleatel <br />APPUCAT1ON IS HERE BY MADE TO THE SAN JOAOIJIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORE DESCRIBED. THIS APPLICATION IS MADE 114 COMPLIANCE MTH SAN <br />JOAQUIN COUNTY DEVELOPMENT TITLE. CHAPTER 9- 1 11 5.3 AND THE STANDARDS OF SAN JO AMIN COUNTY PUBUC HEALTH SERVICES. ENVIRONMENTAL HEALTH D I.N . 50 <br />ORfemAL <br />JOB ADDRESS/OR ARNO 2 067 Zin 4 2211 NI • ti)_A <br />• <br />511- CITY -....5VC11<rejV PARCEL SIZE/APRS <br /> AD,F,E8. RO:Eny T t4103-1 *1-K41.1 45 - PHONE Atel_ <br />A00.Ess 14 5 /4,4 0//4.5660 4"/ uc(.907 <br />577,6<7?w e..4 452as <br />ADDRESS !JCS <br />INTENDED USE <br />INDUSTRIAL <br />DOMESTIC/PRIVATE <br />PUBIJC/PAUNICIPAL <br />IRRIGATION/AO <br />\4,,,,(AONITORING <br />APPROX. DEPTH <br />CONSTRUCTION SPECIFICATIONS A <br />02 " DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING 42 0 <br />TYPE OF CASINWSTEELTRIC 4/74 DIA. OF WELL CASINO A/ %a 0 <br />DEPTH OF GROUT SEAL 5.'"•..5 /- SPECIFICATION R <br />GROUT SEAL INSTALLED BY GROUT BRAND NAME ,,,A!7-4,911.4,..,' ) E <br />(mow SEAL PUMPED T 0 Yon Xi No CONCRETE PEDESTAL BY DIVU-ER: 0 v4.11 Duo s <br />LOCKING CHESTER BOX/STOVE PIPE S <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APR/CATION AND THAT THE WON( WILL SE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES. STATE LAWS. AND RULES AND <br />REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR UCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 1 CERTIFY THAT IN THE PERFORMANCE OF THE WOFK FOR WWII <br />THIS PERMIT 18 ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFOPPSA. CONTRACTOR'S HIRING OR SUS-CONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: CERTIFY THAT IN THE PERFORMANCE 9E THE WORE FOR WHICH THIS PERMIT IS ISSUED, I SHAU- EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CALIFORNIA.' MUE41. 24 HOURS 1 APACE FOR ALL REQUIRED INSPECTIONS AT f 2081 4441.21423. COMPLETE DRAWING AT LOWER AREA PROvvED. <br />D. <br />/PLOT PLAN Si... to googol • to <br />Slonod X Tltlo <br />I. NAMES OF STREETS OR ROADS NEAREST TO OR SOMADING THE PROPERTY. <br />2. OUTLINE OF THE PROPERTY. DIVING DIMENSIONS440 NORTH INFECTION. <br />. DIMENSIONED OtTTUNES AND LOCATION Of ALL EXISTING AND PROPOSED <br />STRUCTURES. INCLUDING COVETED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WAUCS. <br />4. LOCATION OF HOUSE SEWAGE DOSPOSAL SYSTEM OR PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />S. LOCATION OF WELLS IMTHON RAMS OF ONE HUNDRED FIFTY FT. <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />Orout IctosteetIon By <br />Onotruction Inottoo(Ion By <br />Comments! 5,C,12-, <br />Dot• <br />• <br />0.1• <br />OMPL TED <br />)4* " 6p 4o)sc_e <br />ACCOUNTING ONLY: 1 M05 PACO <br />- <br />\IPf64A <br />PE CODES FEE INFO AMOUNT ADMITTED CHECK/MASH RECEIVED B Y DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />2,10 i .-- ift,3 eteef /-2-?-fr -clIelg`2-zy <br />_ <br />_. <br />Pub Health Serv. - Enviro. 173 (1/97) <br />PRONE <br />Dom <br />SUS CONTRACTOR e757 (fr4,e <br />CONTRACTOR GC <br />OWNER'S NAME 01,- <br />TYPE OF WELL <br />0 OPEN BOTTOM <br />0 GRAVEL PACK/SIZE <br />0 OTHER <br />/' <br />Porno In000ttlon By