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ESTRUCTION: <br />jear /tel.& ba.J0e..r <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 />,?,;4 , ,,,-ren.., (4e6t, 707? Pt /.r <br />l'k• GEOPHYSIC/iWELL 0 SOIL BORING <br />tic 41417r -0! <br />• <br />75A <br />rt77‘51%/ <br />a 1031 <br />?-44'4441-0-It• <br />00S-0 _s- 7 <br />APPLICATION FOR WELLIPUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH. SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201.388 <br />(209) 468-3420 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete in Triplicate) <br />APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOPX DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH 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 ADDRESS/OR APNF 2 3'6' Wort 711 2-4A/L-- CITY 4647-:0 L AncEvin ors <br />OWNER'S NAME /104/CV/244)11/ ‘,./TX /439)0 tf r s 114"2"411.4161 ‘f ADDRESS /6! ‘). arY• S.2)0 (pt .5,4*.A/A6.76 POI') 4/.....2.6), 1.2 - 9 5" <br />CONTRACTORAY 4E-A 6,4 71 "51\i" //di< ADDRESS (7/€707L e/Z 14.491" =N.!, .72 is? PHONE /Pea 774c.. <br />PHONE <br /> <br />err1okt...1.7n <br />TYPE OF WELL/PUMP: 0 NEW WELL <br />0 INSTALLATION <br />0 NOW 0 ..._11sp•Ir <br />(TYPE OF PUMP) <br />0 OUT-OF-SERVICE WELL''. <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF WELL EXCAVATION <br /> DIA. OF CONDUCTOR CASING <br />TYPE OF CASING/STEEUPVC <br />DEPTH OF GROUT SEALe <br /> DIA. OF WELL CASING / <br />SPECIFICATION ifler (10"'""1"1 / CA/ I <br />GROUT BRAND NAME GROUT SEAL INSTALLED BY <br />CONCRETE PEDESTAL BY DRILLER: 0 Yee El No GROUT SEAL PUMPED: 0 Yes 0 No <br />LOCKING CHESTER BOX/STOVE PIPE <br />AIR ROTARY AUGER <br /> CABLE OTHER <br />PROPOSED CONSTRUCTION/DRILL1NG METHOD: MUD ROTARY <br />1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOPX WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND <br />REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR UCENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br />THIS PERMIT IS ISSUED, !SHALL NOT EMPLOy4IERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORN1A.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: I CERTIFY THAT IN T r RFORMANCE OF THE WOPX FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />FUAC <br />C <br />ORNIA.' .g.apINT MUIlf C 1/41,24 F.:12yRS ntitDVANCE FOR ALL REQUIRED !NIUE TIONS AT 1205468-3423. cOMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Signed X . I. ..-"P 11 / dr 6 : 7 " r 6-7 ' % I. it.:1 -J .:C. , 'it Mite .7.1- 7 - <br />14 At- LI •-li -41. 4------- <br />ef a e ,....--.7 <br />hie , <br />T e ' <br />PLOT PLAN (Drew to Scale) Scala 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 OUTUNES AND LOCATION OF ALL EXISTING AND PROPOSED <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. <br />72. 6 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />ADDRESS 65,144.7/A C.4 4:;f575'. uc, <br />0 REPLACEMENT WELL 0 MONITORING WELLS 0 OTHER <br />El WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELL I <br />/I.P. DEPTH PUMP SET Fr. FIRST WATER LEVEL <br />4414J -9 ‘,/tI41-2 <br />1.1') /IF <br />9-3 <br />0 <br /> <br />() <br />8 <br />1,06tacPr <br />/4- <br />DEPARTMENT USE ONLY <br />Application Accepted By <br />Grout Inspection By: • ”. •"' PuifriipectIon BY <br />Destruction Impaction By <br />Comments: 111 ,Ai •• ePi2 1 MiGt• <br /> 1- <br />) <br />Date ("? Area 0/ 0 2. <br />••••.-^" ir bate <br />Ikea e/ <br />19A <br />17q <br />ACCOUNTING ONLY: AIDS PAC, <br />-< ( <br />/..> ' <br />.•"-, 1..... <br />L' <br />INVOICE ."-- ---, <br />PE CODES FEE INFO AMOUNT REMITTED CHECK/iCASH RECEIVED BY DATE I . <br />,• .,-• <br />PERMIT/SERVICE REQUEST NUMBER <br />\\ <br />-, 7 <br />/ 41- I-'-.' <br />- r - 31 c . _ . ;-