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SR0035338
EnvironmentalHealth
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1985
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4200/4300 - Liquid Waste/Water Well Permits
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SR0035338
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Last modified
9/16/2022 4:08:07 PM
Creation date
9/16/2022 3:39:32 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
SR0035338
PE
3502
STREET_NUMBER
1985
Direction
W
STREET_NAME
YOSEMITE
STREET_TYPE
AVE
APN
200-140-19-2
ENTERED_DATE
9/19/2003 12:00:00 AM
SITE_LOCATION
1985 W YOSEMITE AVE
P_LOCATION
04
P_DISTRICT
005
QC Status
Approved
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EHD - Public
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APPLICATION FOR WEWPUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />304 EAST WEBER AVENUE, STOCKTON�,ICA 19 2� �� iiEaL�t1 <br />(209) 468-3420 ,a,�� ;=p�►iCE <br />NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br />(C9mpl9t9 In Tr*ficsts) �r �+�p � PM 2. O� <br />APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FORA PERMIT TO CONSTRUCT AND/OR INSTALL THE CRI E . THIS APPLICATION 16 MADE IN COMPLIANCE WTTII SAN <br />JOAQUIN COUNTY DEVELOPMENT TTrLE; CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNT�Y`PU13UC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />1 <br />JOB ADDRESSOR APN/ tILS YC i F m Fir- Avt-wa Crry AUe J � 110Nl�(TQ�� PARCEL SIZE/APN/ Zt)o'(Z <br />OWNER'S NAME GA2V �• rtTEiL. IR JiT �U'�Q'tl �ctr^sADORE6817U Lf:ll(tfU AV�w'V- �I(IN= (A, PtiONE IZO2 6R --ORI <br />CONTRACTOR I MCX / ADDR£BBLb[>_lAA%SO Leo .i1t (ZO SEt)t`L&CTT PHONE / L?/� / /7' q2 <br />RACTOR n M 4f.—Ss G S <br />SUB CONTPECTQJ <br />EkFL�^n�riaJ 23E� L'J1C:(n1AY���lJCK-tum, C,Q. SZor uci Sizi-E,g PHONE #Z61 <br />TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONIrORING WELL IF ❑ OTHER <br />❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS -CONNECT REPAIR ❑ VAPOR EXTRACTION WELL / <br />❑ New ❑ Rov.1, H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br />(TYPE OF PUMP) <br />❑ OUT -OF -SERVICE WELL ❑ OEOPHY61CAL WELL / ❑ SOIL BORING g <br />-;o <br />OESTRUCTION:_ j✓1 W - %✓� �.i% - 2. � (A w- Z <br />I i <br />INTENDED USE TYPE OF WELL CONSTRUC71ON SPECIFICATIONS A <br />❑ INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING D <br />❑ DOMESTIC/PRIVATE ❑ GRAVEL PACK/812E TYPE OF CASINO/STEEL/PVC DIA. OF WELL CASINO D <br />❑ PUBLIC/MUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL SPECIFICATION g <br />❑ IRRIGATION/AO ❑ OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br />❑ MONITORING GROUT SEAL PUMPED: ❑ Y-. [IN. CONCRETE PEDESTAL BY DRILLER: ❑ Y-. ❑ No S <br />APPROX. DEPTH LOCKING CHESTER BOX/STOVE RPE S <br />PROPOSED CONSTRUCtIONrMLUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br />1 HEREBY CERTIFY THAT 1 IIAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND <br />REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR W111CH <br />THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUS -CONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: ' I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CAUFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REGUMED INSPECTIONS AT (2091 444-34211. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Slpr»d X_ ��� �- Tltl- f[-N�C✓l H{��/L()LL�C�>�rzl �1" D.I./ J/ �-?' <br />PLOT PIAN (0— to So.141 Bc-I. ' to <br />1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM on PROPOSED <br />2. OUTLINE OF THE PROPERTY, GIVING DIMEN610N8 AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />3. DIMENSIONED OUTLINFS AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNORED FIFTY FT. <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br />Appil-11 n Apa ptdi By_ <br />0-A I-P-11on By <br />Oe.lrtretlen Imprllpn By <br />Cemmdrt-: <br />Mqp RZLO-c,,�ccc <br />DEPARTMENT USE ONLY <br />O-te Pump I -p-0- By <br />ACCOUNTING ONLY: AID/ FACT <br />D.t. <br />D.le <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK/!CASH <br />RECEIVED BY <br />DATE <br />PERMIT/SERVICE REQUEST NUMBER <br />INVOICE <br />o.06 <br />10 8 <br />14141Z Wjql�g <br />o <br />s 32 8 <br />zt l <br />I <br />Pub. Health Serv. - Enviro. 173 (1/97) <br />
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