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• • <br />INTENDED USE <br />INDUSTRIAL <br />DOMESTIC/PRIVATE <br />PUBLIC/MUNICIPAL <br />IRRIGATION/AG <br />MONITORING <br />APPROX. DEPTH <br />TYPE OF WELL <br />0 OPEN BOTTOM <br />0 GRAVEL PACK/SIZE <br />0 DRIVEN <br />0 OTHER <br />PROPOSED CONSTRUCTION/DRILUNG METHOD: MUD ROTARY <br />PLOT PLAN (Draw to Setae) Scale <br />ETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. <br />THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. <br />NED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED <br />NAME <br />OUTLI <br />DIME <br />'MENT <br />) 9 loqq ,„. <br />Ty <br />IS tt <br />HE By $4AocTo 73E.t4AIN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />okat+ER 9-1 1 1 5.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR APN /1/0 ...S7-4'.1771e t-Ltl crre c-kt 4-7 4 e PARCEL SIZE/APN# / 4 <br />CONTRACTORS)c:c-i-vc4 vvt , p c• -v• <br />SUB CONTRACTOR <br />ADDRESS UCI <br />PHONE # <br />TYPE OF WELL/PUMP: 0 NEW WELL <br /> O REPLACEMENT WELL <br /> <br />O MONITORING WELL # <br /> O OTHER <br />0 INSTALLATION <br /> O WELL SYSTEM REPAIR <br /> O CROSS-CONNECT REPAIR <br /> O VAPOR EXTRACTION WELL # <br />0 New 0 Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br />0 <br />(TYPE OF PUMP) <br />OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL # 0 SOIL BORING • <br />Vi DESTRUCTION: 3 2A Ex r) )4 t cc e I *; a -1-cibo s, presso rrast- <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASINO D <br />TYPE OF CASING/STEEL/PVC DIA. OF WELL CASING DO„ <br />DEPTH OF GROUT SEAL SPECIFICATION R r., <br />GROUT SEAL INSTALLED BY <br />GROUT BRAND NAME <br />S <br />;Ifs <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 AN0c4,-. <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 WHICH1 <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 AT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CALIFORNIA.: 24 HOURS IN ADVANCE FOR ALL REQUIRED I PECTION6 AT 120411 455-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Signed X Title >r45Z11/7L Data /P .Tb'c: <br />APPLICATION FOR WELLIPUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201-388 <br />(209) 468.3420 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete in Triplicate) <br />OWNER'S NAME /1/02,14 ADDRESS R7 ex.9‘... 2 4 cc/ 7,546rd) PHONE # <br />ADDRESS 2 uct_3/224-e, PHONES <br />GROUT SEAL PUMPED. 0Y.. 0 No CONCRETE PEDESTAL BY DRILLER: 0Y.. 0 No <br />LOCKING CHESTER BOX/STOVE PIPE <br />AIR ROTARY AUGER CABLE OTHER <br />" to <br />STRUCTURES, INCLUDING COVERED 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 />ON THE PROPERTY OR ADJOINING PROPERTY. <br />44 - <br />13u mer <br />DA .j':1 i? C <br />DEPARTMENT USE ONLY <br />Application Accepted By <br />Date Area P <br />Grout Inspection By , Is <br /> <br />Date '2_ ( Pump Inspection By <br />Data <br />Destruction Inspection By <br />Date <br />Comments: M.tif c 9 kt-ti,k(i, <br />ACCOUNTING ONLY: AIDS FAC# .31.—n ( Z - <br />PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />6:0c,Lylit2q 4„. <br />C6,k000 g 39s—