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'N 6.03 LL <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 1 I L <br />(209) 468.3420 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Oomph(' In Triplicate) <br />APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1115.3AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR APNO CITY S4C/C efEll PARCEL SIZE/APNE tel <br />OWNER'S NAME (--; &)/26-r--- /L/1 ADDRESS paigtv: et-51 9?..c.20. PHONE E(4 -57 7/ <br />CONTRACTOR 7a4A — • RESS alt;124:4X-El- CE PHONE <br />SUB CONTRACTOR ADDRESSE:71.565 tt1i7t0/41 C11)( UCE50•441 6:WE L! 7 )2--- <br />NEW WELL <br />INSTALLATION <br />0 New 0 Repair <br />REPLACEMENT WELL <br />WELL SYSTEM REPAIR <br />H.P. <br />OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL S SOIL BORING <br />MONITORING WELLE <br /> O OTHER <br />0 CROSS-CONNECT REPAIR <br /> O VAPOR EXTRACTION WELL E <br />DEPTH PUMP SET FT. FIRST WATER LEVEL 0 <br />8 <br />(.51 <br />TYPE OF WELL/PUMP: <br />(TYPE OF PUMP) <br />0 DESTRUCTION: <br />INTENDED USE TYPE OF WELL <br />0 INDUSTRIAL 0 OPEN BOTTOM <br />DOMESTIC/PRIVATE [GRAVEL PACK/SIZE A 3 <br />PUBLIC/MUNICIPAL 0 DRIVEN <br />IRRIGATION/AG 0 OTHER <br />MONITORING <br />APPROX. DEPTH 25' <br />PROPOSED CONSTRUCTION/DRILUNG METHOD: MUD ROTARY <br />CONSTRUCTION SPECIFICATIONS , A NI <br />DIA. OF WELL EXCAVATION in ' DIA. OF CONDUCTOR CASING C'/V//4 ( 17* <br />TYPE OF CASING/STEEL/PVC Pi, j4:-. DIA. OF WELL CASING 4-• 04, <br />DEPTH OF GROUT SEAL S'Ir.,A E•f-at C SPECIFICATION c-C-1•E 40 a 0 <br />GROUT SEAL INSTALLED BY Cel1'4lraL4C're GROUT BRAND NAME E <br />GROUT SEAL PUMPED: [4 Yes 0 No CONCRETE PEDESTAL BY DRILLER: CI Yee 0 No S t <br />LOCKING CHESTER BOX/STOVE PIPE reS S <br /> AIR ROTARY AUGER CABLE K. OTHER <br />U` <br /> '.1 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 LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I 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 LIONS 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 />CALIFORNIA.", 7 APPLI NT MOS CALI. 4 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12051 4054423. COMPLETE DRAWING AT LOWER AREA PROVIDED. I <br />Signed X 1 /ee eiN -Ce 41 TIIIE I'S /...7. --644ty/7ia-, fr." D.,. 4122/96. <br />PLOT PLAN (Draw to Scale) Scale ' to <br />I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. <br />OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. <br />DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED <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 /> pAYMENT <br />RECE7tiEb <br />DEPARTMENT USE ONLY <br /> MAY 6 1996 <br /> <br />L:citmq PQBLIO <br />ENV RO <br />HEALTH ERVICES M/1EN AL HEALTH DtVISION. <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />Comments: <br />Date 6/fk Area <br />Date Pump Inspection By <br />EXPIRE., Date <br />Date <br />ACCOUNTING ONLY: AIDE FACE <br />PE CODES FEE INFO AMOUNT REMITTED „,.......7C9/CASH RECEIVED BY DATE <br />--- <br />yERMIT/SERVICE REQUEST NUMB INVOICE <br />tqD \ 61 .....-.-- <br />,,,,(°71110 q ID iC 0.27&.7/ „ ... _ (