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APPLICATION FOR WELLIPUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVI(.__ �D qv <br />ENVIRONMENTAL HEALTH DIVISION 2. <br />P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br />(209) 466.3420 <br />NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED <br />(CBmpM(e In Triplknle) <br />APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/on INSTALL THE WORK DESCRIBED. Title APPLICATION IS MADE IN COMPLIANCE WRIT 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 ADDRESSOR APN7 1305 Escalon Avenue Escalon <br />CIT'1 PARCEL 912E/APNI Q <br />OWNER'SNAME City of Escalon 246 <br />ADORESSP. O. BOX PHONE.838-41 OO <br />coNTRAcToR_ V & W Drilling ADORES e15 Espeerson Ct Rio irsta 720904ONE.707 374-280; <br />; <br />SUB CONTRACTOR ADDRESS LICe PHONE <br />TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONFTORINO WELL E ❑ OTHER._PC)rp Cll P <br />❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS -CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J <br />(TYPE OF PUMP) 11 Now ❑ Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL U / <br />(Ty- 11OUTF -OSERVICE WELL ❑ GEOPHYSICAL WELL I 11 SOIL BORINGEnvironmental <br />❑ DESTRUCTION: grout via pressure methods Q <br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Af \� <br />11 INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASINO p\\/i <br />❑ OOMESTIC/PRIVATE ❑ GRAVEL PACK/SIZE TYPE OF CASINO/STEEUPVC DIA. OF WELL CASINO D <br />❑ PUBLIC /MUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br />❑ IRRIGATION/AG OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br />131 MONITORING GROUT SEAL PUMPED: ❑ Ys [IN. CONCRETE PEDESTAL BY DRILLER: ❑ Yee [IN. g <br />APPROX. DEPTH LOCKING CHEBTEn BOX/STOVE PIPE S <br />PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER X CABLE OTHER <br />1 HE"Y CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND 1/ / <br />REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICII <br />THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB -CONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: ' 1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERBONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CAUFORNI(A-'�THE rAJIPPUCANT UT CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED /INS TIONS AT 1 (,!(]1409-3422. COMPLETE DRA 4441NO AT LOWER AREA PROVIDED. <br />signed X �l c ,�/� — ' /C Tine_ _ 07- Ll.� I— '_ P <br />PLOT PLAN (Drew to Scale) Seats ' to <br />1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />OF <br />�. LOCATION GGG <br />2. OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION F SEWAGE DISPOSAL SYSTEMS. <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 />See Attached Map <br />Application Accepted By L.�_ I \�t <br />Orout impectlen By. G A% (,N— wnn e -9A, Date'1-" 12' <br />v—, z z <br />Oeatnrcllen Inepx.11— By O <br />DEPARTMENT USE ONLY <br />P—p Impaction <br />Date IL Area <br />Dale <br />ACCOUNTING ONLY: <br />AID# <br />FACT <br />il <br />PE CODES FEE INFO <br />AMOUNT REMITTED <br />CHECK/ICASN RECEIVED BY DATE <br />IT/SERVICE REQUEST ER INVOICE <br />5"0 <br />013(U Ii <br />ZPO L% 33 <br />Pub. Health Serv. - Enviro. 173 (3/96) <br />