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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 95201-388 <br />(209) 468-3420 <br /> <br />PARCEL SIZE/APNE <br />OWNER'S NAME jr: e t- ADDRESS 117 73C (.4./ • Fly A t PCX/6 1) PHONE E (/ :301 O L// <br />5c, i1/2-....;f1kA-kc', /4'1 C(47): ADDRESS 171c.,Nki,ti S 441c# - - Piior?irj#9 -3 7 CONTRACTOR <br />SUB CONTRACTOR 5reC f t .yit) ADDRESS 236' 5- 141/9 bac# 572 z653 pa? VG" S 7/ <br />TYPE OF WELL/PUMP: 0 NEW WELL <br /> <br />0 REPLACEMENT WELL ErMONITORING WELL St /14 14/ -e"1-1 0 OTHER <br />0 INSTALLATION <br /> <br />0 WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELL it <br />0 New 0 Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br />(TYPE OF PUMP) <br />0 OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL I 0 SOIL BORING <br />ZERUCTION:c,'frecciiir IIM1 fO1)fft., (ii;) II 1:11;17N tcr 14, <br />INTENDED USE <br /> TYPE OF WELL <br />INDUSTRIAL <br /> <br />0 OPEN BOTTOM <br />DOMESTIC/PRIVATE <br /> <br />0 GRAVEL PACK/SIZE <br />PUBLIC/MUNICIPAL <br /> <br />0 DRIVEN <br />IRRIGATION/AG <br /> <br />0 OTHER <br />MONITORING <br />APPROX., DEPTH id) <br />oo <br />I HEREBY CERTIFY THAT I 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 UCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <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: I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CAUFORNIA.- THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12091468-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Title Tr-soi e_c( Date OA/ 17 Rs- <br />NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete in Triplicate) <br />APPUCATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOPIC DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1 1 1 5 .3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR APNE ( 5 C .19/ir Rc.4 CITY '5 /---/< tO/ A <br />PROPOSED CONSTRUCTION/DRILLING METHOD MUD ROTARY <br />CONSTRUCTION SPECIFICATIONS <br /> <br />A <br />DIA. OF WELL EXCAVATION S - I tC-4 i . "k ' DIA. OF CONDUCTOR CASING .D <br />PE TY OF CASING/STEEL/PVC $CL.1) , L7/ C; '•/1 t. '.C.- DIA. OF WELL CASING ::a -'1.11C-il D <br />DEPTH OF GROUT SEAL 0 Fr— O. <br />3 <br /> FT SPECIFICATION <br />GROUT SEAL INSTALLED BY k'' c-e- 1 rt-cli GROUT BRAND NAME E <br />R <br />GROUT SEAL PUMPED: El Yea 0 No CONCRETE PEDESTAL BY DRILLER: Eri;:s 0 No S <br /> <br />LOCKING CHESTER BOX/STOVE PIPE S <br />AIR ROTARY Le AUGER X CABLE OTHER <br />Signed X vou- 14.0-yrtauf <br />PLOT PLAN (Draw to Scale) Scale to <br />NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. <br />OUTUNE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. <br />DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED <br />STRUCTURES, INCLUDING COVEnED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. <br />LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />i HE PROPERTY' OP FE),..01NING PRO./ PTY. <br /> 04111111111/ <br />- fre,e_421-Irk <br />. :MAL, H If/ALT' --, <br />PEWIT I ' ' SEPVICES <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection B <br />Comments: <br />DEPARTMENT USE ONLY <br />F717 7 ry,,,,gr <br />oat. r I p 15 Are. a <br />Pump Inspection By <br />ACCOUNTING ONLY: AIDS FACE <br />PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECEI D BY PERMIT/SERVICE REQUEST NUMBER INVOICE <br />350 2111.- WI) <br />0 /Of <br />110 <br />7 ,k_o-7011, <br />S c“)0 70