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APPLICATION FOR WELL/PUMP PERMIT v c =b <br />OV 2 3 1998 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />F'IuNTY 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br />SE <br />J +' ; !' LTH RVICES <br />ENVIRONMENTAL HEALTH DIVISICi�! (209) 468-3420 <br />NON•REFUNOARLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />ICompkto IB Tripikata) <br />FACE <br />APPLICATION 19 HM BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WNII SAN <br />JOAQUIN COUNTY DEVELOPMENT TR , CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />1 '^� 1[� y <br />JOB ADORE39A]R APNI �{L'�-1 i.I-il.�� CIT/ J���=�T�1 <br />PARCEL SIZE/APTII <br />F- <br />OWNER'S NAME 4JrI�' 1 1�'�1„�� 1:21 <br />L <br />\�J ADDRESS „„ C., IY' /.15 <br />�„ig �,� PHONE f <br />COMPACTORJ�' ��) 1?( `i �� I I"�I.-= c— ADDRESS J -r 4.4 <br />CI6 5U2Z,..,.ONE I 7z5'- 313 -c, <br />OR88��UC! TU� PON/SUS CONTRACTOR U q—a�(1 3l <br />_J <br />TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL / <br />❑ OTHER <br />❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS -CONNECT REPAIR <br />❑ VAPOR EXTRACTION WELL / <br />❑ New 11pe <br />ReH H.P. DEPTH PUMP SET FT. <br />•/ <br />FIRST WATER LEVEL O <br />R YPE OF PUMP) <br />❑ OUT -0F -SERVICE WELL ❑ GEOPHYSICAL WELL I <br />❑ DESTRUCTION: <br />A <br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br />❑ INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WELL EXCAVATION <br />DIA. OF CONDUCTOR CASINO p „ <br />❑ DOMESTICMRIVATE ❑ GRAVEL PACK/SIZE TYPE OF CASING/STEEUPVC <br />DIA. OF WELL CASINO D <br />❑ PUBUCIMUNICIPAL DEPTH OF GROUT SEAL <br />SPECIFICATION q ! <br />[❑(DRIVEN <br />❑ IRGATION/AG L'J O <br />RITHER GROUT SEAL INSTALLED BY <br />GROUT BRAND NAME F <br />❑ MONTTORING GROUT SEAL PUMPED: ❑ Yee [IN. <br />CONCRETE PEDESTAL BY DRILLER: ❑ Y« ❑ Ne 5 <br />APPROX. DEPTH LOCKING CHESTER SOX/STOVE RPE <br />PROPOSED CONSTRUCTIONIMLUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br />I HE9EBY CERTIFY THAT I HAVE PREPARED THIS ATION ANO 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. I E OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br />THIS PERMIT 18189 PD, 1911AL1 NO PLOY NO SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTWO SIGNATURE CERTIFIES <br />THE FOLLOWING: CE T ATN IE ANCE OF THE WORT( FOR WHICH THIS PERMrT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CALIFORNIA.' T A CAN VST C IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12O*) 40fJS22. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />$Ipned Title <br />PLOT PLAN IDrew to Sadel Scale to <br />1. NAMES OF STREET$ 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 ANO LOCATION OF ALL EXISTING AND PROPOSED a. LOCATION OF WELLS WRHIN PAM$ OF ONE HUNDRED FIFTY FT. <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINSYG PROPERTY. <br />Applleetbn Aceepted <br />Grout Inspection By <br />O—I'm0en I—P-0— By <br />DEPARTMENT USE ONLY <br />Inspectlon <br />Date (I -,-.L-O.F. <br />Date <br />ACCOUNTING ONLY: <br />AID/ <br />FACE <br />PE CODES FEE INFO <br />AMOUNT REMITTED C HEq*.97C ASH <br />RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />3Soi OS <br />b <br />10 1-7 LA <br />Pub Health Serv. - Enviro. 173 (1/97) <br />