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Th i 5I 1 <br /> F:ii<c1 <br />Coverea) <br />e ei <br />... <br />Utrn s (air, <br /> Sea te <br />. ;!..1—.) d4-) rtli I <br /> cA) <br />-1. /LS__ IJILW 'MUM/ <br />DEPARTMENT USE ONLY <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspecti jhr <br />Comments: <br /> Date / <br />Dal* Pump Inspection By <br />Date <br />ACCOUNTING ONLY: <br /> <br />I AIDS <br /> <br />I FACO <br />PE CODES FEE INFO AMOUNT REMITTED _Slyie ASH <br />76/ <br />RECEIVED BY DATE <br />f/Z7 <br />PERMIT/SERVICE REQUEST NUMBER <br />6:11/./ //,j6 <br /> <br />z 0-74 <br />Area <br />Date <br />INVOICE <br />APPLICATION FOR WELLIPUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIGES <br />ENVIRONMENTAL HEALTH DIVISION <br />P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201-388 <br />(209) 4981420 <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 WORK DESCRIBED. THIS APPUCATION IS MADE IN COMPUANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE. CHAPTER 9-1 1 1 6.3 <br />AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR APNS 25- ea Y -0 in ado Ave crnr <br /> ,.._, <br />-:> (-0('-'/I-C/31 PARCEL SIZE/APNS ,56/ 4 ,..... <br />1 <br />OWNER'S NAME j i c**//11/5.0 r) Ca. ADDRESS P. 0. 159X 86.4C.) ,S74-C-X '',LEn/L9QC6PHONE # 4/-4- 77 CONTRACTOR 4-7-7E' <br />SUB CONTRACTOR <br />ADDRESS ' <br />;el-ii:thg"- itz -ucs 7CVA.)- 63. PHONES a / V <br />ADDRESS <br />UCS PHONE I <br />TYPE OF WELL/PUMP: 0 NEW WELL <br />0 INSTALLATION <br />0 New 0 Repair <br />(TYPE OF PUMP) <br />0 DESTRUCTION: <br />0 REPLACEMENT WELL 0 MONITORING WELLS 0 OTHER <br />0 WELL SYSTEM REPAIR <br />H.P. <br />0 CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELL,________ J <br />DEPTH PUMP SET FT. ' FIRST WATER LEVEL 0 0 OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELLS 17.1 SOIL BORING a <br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 0 INDUSTRIAL 0 OPEN 80 OM ..,.) ,„,.., .4 <br />DIA. OF WELL EXCAVATION .7-' DIA. OF CONDUCTOR CASING cilq D 0 DOMESTIC/PRIVATE 0 GRAVE/PACK/SIZE TYPE OF CASING/STEEL/PVC /Warn t*. DIA. OF WELL CASINO it ett..A; D 0 PUBUC/MUNICIPAL 0 DRI N DEPTH OF GROUT SEAL cer el- 0.,- e-- SPECIFICATION ,/(:///f- R 0 IRRIGATION/AG 0 0 HER GROUT SEAL INSTALLED BY '7 d,...-- GROUT BRAND NAME 121 MONITORING E colour SEAL PUMPED: SI Yee 0 No CONCRETE PEDESTAL BY DRILLER: 0Y.. 0 No s <br />PROPOSED CONSTRUCTION/DRIWNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATION 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: '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 LAWS OF CAUFORNIA.' <br />THE FOLLOWING: ' I CERTIFY HAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WOFUKMAN'S COMPENSATION LAWS OF CALIFORNIA.' TH MUST C <br />HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br />HOURS IN ADVANCE FOR AU. REQUIRED I MOTIONS AT 2011) 44141423. COMPLETE DRAWING AT LOWER AREA PROVIDED, <br />Signed X /./1) <br /> Title .,07/c0/ g/1 t— Date <br />PLOT PLAN 'Drew to Soo'.) Scale NAMES REETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. <br />01JTUNE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. <br />DIMENSIONED OL/TUNES AND LOCATION OF AU. EXISTING AND PROPOSED <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS. DRIVEWAYS, AND WALKS. <br />' to <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 />APPROX. DEPTH LAD <br />LOCKING CHESTER BOX/STOVE PIPE