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evs oz y <br />APPLICATION FOR WELL/PUMP PERM" <br />SAS_ JAQUIN COUNTY PUBLIC HEALTH SE, _,CES <br />ENVIRONMENTAL HEALTH DIVISION <br />304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br />(209) 468-3420 JAN 1 1999 <br />NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br />(Complete In Triplicate) <br />APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/Ort INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR APNIV e- O/�yr/���� `'`�L!�� CITY Tj oTT—�/ ff PARCEL SIZE/APNI <br />OWNER'S NAMEI{✓y%�//� /�/ /A!T(/�V/ - -PuUc y�J✓C�'� ADDRESS � -7 /�p�,( /e {J, PIIONE A' ✓9��-7 ��icD <br />CONTRACTOR �p 1r L� l/CC (/y/� ` '�Q ��I�� II�G✓%AC ADDRESS y�/VO4 ILj yW/o� I,S/i/�� (JCA t,u��Q� PHO (OEp1 '6q / /0 <br />SUR CONTRACTOR SQ I S' 6 A_ ��. 2— <br />ADDRESS <br />I / 94 UC/ �Iri (INE ISG" Z �Z 2 -- <br />^� 2 <br />TYPE OF WELL/PUMP: 0't NEW WELL <br />'❑ <br />11REPLACEMENT WELL MONITORINO WELL/ 7/ TJ <br />❑ OTHER <br />PE CODES <br />FEE INFO <br />INSTALLATION <br />❑ WELL SYSTEM REPAIR ❑ CROSS -CONNECT REPAIR <br />❑ VAPOR EXTRACTION WELL I <br />J <br />s o <br />❑ New 11 Repel/ <br />H.P. DEPTH PUMP SET FT. <br />FIRST WATER LEVEL /to <br />O <br />IT YPE OF PUMP) <br />❑ OUT -OF -SERVICE WELL ❑ GEOPHYSICAL WELL if <br />❑ SOIL BOnING <br />g <br />❑ DESTRUCTION: <br />INTENDED USE <br />TYPE OF WELL <br />CONSTRUCTION SPECIFICATIONS <br />A <br />El INDUSTRIAL <br />❑ OPEN BOTTOM <br />�f� <br />DIA. OF WELL EXCAVATIONU�f h <br />%d <br />DIA. OF CONDUCTOR CASING / "r�' r <br />D <br />ElDOMFSTIC/PRIVATE <br />1:1 GRAVEL PACK/SIZE TYPE OF CASINO/STFF-12 ?l�LC - <br />DIA. OF WELL CASING 4 T� _ <br />p <br />El PUBLIC /MUNICIPAL <br />❑ DRIVEN <br />DEPTH OF GROUT SEAL 57L,-fAc2 �rs <br />SPECIFICATION <br />R <br />El1 IGATIONIAG <br />❑OTHER <br />GROUT SEAL INSTALLED BYF�-7� <br />GROUT BRAND NAME <br />F <br />ONITORING <br />GROUT SEAL PUMPED: ❑ Yee la No <br />CONCRETE PEDESTAL BY DRILLER: ❑ Yee No <br />S �G <br />APPROX. DEPTH <br />�+ / (,mac-/ <br />LOCKING CHESTER BOX/8TOVE PIPE <br />_ <br />S <br />PROPOSED CONSTRUCTION/DRILLING <br />METHOD: <br />MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br />C <br />I HE9ESY CERTIFY THAT 1 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 CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br />THIS PFRMIT IS ISSUED, 1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB -CONTRACTING SIGNATURE CERTIFIES ' <br />THE FOLLOWING: ' I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CALIFORNIA.'�THE <br />)APPUC T MUST CALL 244/(FJ�O'{,URRS, IN <br />INN -ADVANCE FOR ALL REQUIRED IN[SPPEECTIIOON�S AT 112201111 44693423. COMPLETE DRAWING AT LOWER AREA PRO VID D. 9 �� <br />Sloned X (/(/C /1'!� v Title <br />PLOT PLAN IOrow to Spelel Scde to D <br />1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISP09AL SYSTEM OR PROPOSED <br />7. OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SY8TFMS. <br />3. 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 />�<....I._ <br />Applketlon Aec <br />Grout Inepectlon <br />CernTel W <br />DEPARTMENT USE ONLY <br />epteA Dote Z A— <br />BY / CI P1 Dote ' ' Ptmtp Inep-tlon By Dote <br />Soden By Dote <br />ACCOUN TING ONLY: <br />AID,( FACd 11 <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK+(/CASH <br />RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER <br />INVOICE <br />s o <br />a <br />IlT190 <br />I �- v US <br />Pub. Health Serv. - Enviro. 173 (1/97) \- <br />