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APPLICATION FOR WELL/PUMP PERMIT <br />SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION �s <br />304 EAST WEBER AVENUE, STOCKTON, CA 95202 " s <br />d,; q (209) 4W-3420 N O V 10 1998 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complots In TripResla) <br />APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN <br />JOAQUIN COUNTY DEVELOPMENT TrTLE CHAPTfJI 9-1115.3 AND THE STANOARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />�2 S _ <br />JOB ADDRESSOR APNI L7 KA A/ 1 L -I 1, I� CITY H Cr Y PARCEL SIZE/APN/ .Z I ' (i L li <br />OWNER'S NAME ft /� L'. V' ADDRESS E }'i 1 ��/ / I�I°� } C /)- PHONE R <br />r?✓>/n/tSs /jam'""/ 33� <br />CONTRACTOR 1 I. G 1/ t:1 ADDRESS C c-,/ TC /z C> ^ UCI PHONE I L / t L <br />SUR CONTRACTOR V z1 W ADDRESS 1: " 5/ UCI L h 7 PHONE I L 5 l ti <br />I" <br />TYPE OF WELUPUMP; ❑ NEW WELL ❑ REPLACEMENT WELL iia -MONITORING WELL # 1 ❑ OTHER <br />❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS -CONNECT REPAIR ❑ VAPOR EXTRACTION WELLI J <br />❑ New ❑ Rgnh H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br />(TYPE OF PUMPI <br />❑ OUT -OF -SERVICE WELL ❑ OEOPHYSICAL WELL I ❑ SOIL BORING B <br />%' 9 6,5 1, AZ (7 h e )% .2- Z Z I l3 C1 5 0✓ �_ /°, r 9 1 L- L 5✓ k r te-1 C 17 - Z- 1 <br />❑ INDUSTRIAL ❑ OPEN BOTTOM <br />❑ DOMESTIC/PRIVATE ❑ GRAVEL PACK/SIZE <br />❑ PUBLIC /MUNICIPAL ❑ DRIVEN <br />❑ IRRIGATION/AG ❑ OTHER <br />❑ MONITORING <br />APPROX. DEPT" Z Z 1 L7 5 S <br />PROPOSED CONETRUCTION/DR (LUNO METHOD: MUD ROTARY <br />DIA. OF WELL EXCAVATION <br />TYPE OF CASINO/STEEUPVC <br />DEPTH OF GROUT SEAL <br />DIA. OF CONDUCTOR CASING 0 <br />DIA. OF WELL CASING 0 <br />SPECIFICATION <br />GROUT SEAL INSTALLED BY GROUT BRAND NAME <br />GROUT SEAL PUMPED: ❑ Y.o ❑ No CONCRETE PEDESTAL SY DRILLER: ❑ Yw [IN. <br />LOCKING CHESTER BOX/STOVE RPE <br />AIR ROTARYAUGER CABLE OTHER <br />I HE9E9Y CERTIFY THAT 1 NAVE 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: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br />THIS PERMIT IS ISSUED, I SMALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: ' 1 CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSON@ SUBJECT TO WORK]MAN'S COMPENSATION LAWS OF <br />CALIFORNIA.' THE APPUCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOUMED INSPECTIONS AT 12091441044". COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />SlOned x ,- Title'5'7( <br />t % F h/! / f✓9 < D <br />PLOT PLAN Mw- to So.lel Sa.l. ' to <br />1. NAMES OF STREETS 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 />J. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />STRIICTURE@. INCLUDING COVERED AREAS SUCH AS PATIOS. DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br />j1 DEPARTMENT USE ONLY <br />AOPSc.11en Aec,,. BY 1.4 �/ `' �-�. � - ----Dole <br />O—A IMPeellen <br />PR p In.Peetlen By <br />Cemmer,,.:c j'� �^, l�'1✓�+...0 -^--.' �l i �' ° .W. r �_9 [� GV 'i. i+ LL-/�. "' - "-'�1--> 1•'T <br />Dot. <br />ACCOUNTINO ONLY: <br />AID# <br />FAC# <br />PE CODES FEE INFO AMOUNT REMITTED <br />�'+ <br />CHE01K ICASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER <br />INVOICE <br />taro. c, i l <br />sf 11 S f�D <br />Pub Health Serv. - Enviro. 173 (1/97) <br />