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APPLICATION FOR WELLIPUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201388 <br />(209) 468-3420 <br />NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete in Triplicate) <br />APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WOR( DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WIT14 SAN <br />JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9 1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOBADDRESS/ORAPNO 404 West Fremont Street , Stockton PARCEL SIZE/APNS <br />OWNER'SNAME Crystal Cream & Butter ADnnFSSJ013 D Street, Sac, PHONE, 444-7200 <br />CONTRACTORWallace-Kuhl & Associates ADDREGE3050 Industrial BIVd* WestSaC J`HONE 1372-1434 <br />SUBCONTRACTOR WESTEX M1 ADDRES` IeS U. ox LIC. 552198 PHONE/ 373-1118 <br />TYPE OF WELVm1MP: ❑ NEW WELL ❑ REPLACEMENT WELL. LY MONITORING PILL I MYV7 ❑ OTHER <br />❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J <br />❑ N— C1PP-.(,11. P. DFPTU PUMP SET_FT. FIRST WATER LEVEL 2 5 feet <br />eet O <br />HYPE OF PUMP( <br />❑ OUT -OF SERVICE WELL ❑ GEOPHYSICAL WELL / ❑ BOIL BORING B <br />❑ DESTRUCTION: <br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br />❑ INDUSTRIAL El S OPEN BOTTOM DIA. OF WELL EXCAVATION Inch DIA, OF CONDUCTOR CASINO 411 O <br />❑ DOMESTIC/PRIVATE IOGRAVELPACK/512E#3 Sand TYPE OF CASINGISTEEIJPVC PVI,. DIA, OF WELL CASING 211 O <br />❑ PVBLIC/MUNICIPAL 11 DRIVEN DEPTH OF GROUT SEAL 21 feet_ SPECIFICATION ri <br />—trgra---BruTaro 17 E <br />❑IRRIGATION/AG ❑OTHER GROUT REAL INSTALIFOwwBVsrerni a GROUT BRAND LIME �--Y.Ag1IRA& Ggim Er <br />a MONETONNG GROUT SEAL. PUMPED. )[X-[IN.ET <br />N. CONCREPEDES AMLBVDRNLLFR:®Ye. [IN. S <br />APPROX. DEPTH 40 Feet LOCKING CHESTER BOX/STOVE PIPE S <br />PROPOSED CONSTRUCTIONIDICWNO METHOD: MUD ROTARY AIR ROTARY AUGER X CABLE OTHER <br />I HERESY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT T/IE WOW 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: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br />THIS PERMIT IS ISSUED. 1 8HALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S 14IMNO OR OUR SIGNATURE CERTIFIES <br />THE FOLLOWING: ' 1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH TIIIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CALIFORNIA���y .'/yTHE APPLICANT MUST 34 HOUIIS IN ADVANCE FOR ALL REQUIRED !INSPECTIONS AT 11051 46SJ423, COMMETE DRAWING AT LOWER AREA PROVIDED. <br />-{/'2Z,iEI`Tltl. `a Vr- \ &EoLG£{2 <br />(.1sr-�k/'L D.t. -Q <br />SlpnedX <br />PL PLAN IDr 11 So.1e1 Srela ' to <br />1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PR0MSFD <br />2. OUTLINE OF THE PROPERTY. GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF 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 T14E PROPERTY OR ADJOINING PROPERTY. <br />FrzEMovr CTREET- <br />P-ROP056O <br />T -FLEE mmSTog, <br />bRRw <br />P1rGH Vna,lr4 G -E LIAR <br />$rDFwAtic _.-� T <br />NTRut'( PaLE O <br />1 <br />4TILITi <br />AIMEPIcAN PRGTECTIvF- ROX W <br />N,ER <br />SEQu1CF_t F3LDG. MSE) 1 <br />w <br />3 <br />m <br />$cul2: to t`F <br />t0 Z <br />DEPARTMENT USE ONLY /,(f <br />APPIIE.11en Accepted By a��D.te / V Are. <br />Grolrt Iropeclon By 2 D.te Pump Iropeotlon BY Det. <br />Deelrtcllon <br />1- 11— By D.te <br />ACCOUNTING ONLY: <br />I AIDS <br />I FAC/ <br />11 <br />Ll <br />q6--121 <br />PE CODES FEE INFO <br />AMOUNT REMITTED <br />CHEC CASH <br />RECEIVED BY <br />DATE <br />PERMIT/SERVICE REQUEST NUMBER <br />INVOICE <br />bC, <br />