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0 GEOPHYSICAL WELL I 0 OUT-OF-SERVICE WELL <br />4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM on 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 />PLOT PLAN (Draw to *Motel Seals ' to <br />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 />PROPOSED CONSTRUCTIONIDRILUNO METHOD: MUD ROTARY <br />Title Slgood <br />Application Accepted By <br />Otani Inapoction By <br />Area <br />Dote Pump Impaction By <br />APPLICATION FOR WELL/PUMP PER. <br />SA -MOWN COUNTY PUBLIC HEALTH SL iCES <br />ENVIRONMENTAL HEALTH DIVISION <br />304 EAST WEBER AVENUE, STOCKTON, CA 95202 <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 WOW DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />JOAOUIN COUNTY DEVELOPMENT TITLE. CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVMONMENTAL HEALTH DIVISION. <br />OWNER'S NAME Frt2 //k 6v in ADDRESS 20 7 Z- ,/1)' <br />CONTRACTOR S CIL ki krt.h.tm .,.4.14/ ADDRESS 5,9 Si.cei <br />SUB CONTRACTOR ADDRESS <br />TYPE OF WELUPUMP: 0 NEW WELL <br />0 INSTALLATION <br />0 Now 0 Repel, <br />0 REPLACEMENT WELL <br />0 WELL SYSTEM REPAIR <br />H.P. <br />0 MONITORING WELL I <br />I: 1 CROSS-CONNECT REPAIR <br />DEPTH PUMP SET FT. <br />(TYPE OF PUMPI <br />0 DESTRUCTION: <br />CONSTRUCTION SPECIFICATIONS <br />a." <br />GROUT SEAL INSTALLED avTrAktir <br />GROUT SEAL PUMPED: DV.. 0 No <br /> <br />LOCKING CHESTER BOX/STOVE PIPE <br />AIR ROTARY AUGER <br />I LIE.EBY 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: 1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW 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 VVOFE FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CALIFOR HE A T CALL 24 HOURS IN ADVANCE FOR ALL REOU/RED INSPECTIONS AT 12011) 45114423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />ces‘A c-- <br />Cs7 Z tk.). 0 .V144 1*-/eA tie J013 ADDRESS/OR APSIS Cr, "fe c PARCEL SIZE/APNO 2 q 1c'ZI 7 <br />DIA. OF WELL EXCAVATION <br />TYPE OF CASING/STEEL/PVC <br />DEPTH OF GROUT SEAL <br />"d\ <br />D.eiroctlen tn.,Tion By <br />Comment,: <br />ACCOUNTING ONLY: AIDS FACS <br />5‘900 1 a I :2,___. <br />IN PE CODES FEE INFO AMOUNT RWTED CHECKS/CAS/4 RECEIVED BY DATE PERMIT/SERV10E REQUEST NUMBER <br />)6tn CO/ VI" 'Lc 31 Li/46 -1 0111 'S <br />Pub. Health Serv. - Enviro. 173 (1/97) <br />Dote <br />INTENDED USE <br />0 INDUSTRIAL <br />0 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 />'DRIVEN <br />El OTHER <br />Y-6 /41/ , JP (le I) -7 71' <br />? LICE 249 ZZG PHONES 7 7 Z-3576 <br />LICO PHONE I <br />OTHER <br />VAPOR EXTRACTION WELL <br />FIRST WATER LEVEL <br />Jill SOIL BORING <br />DIA. or CONDUCTOR CASING <br />DIA. OF WELL CASINO <br />SPECIFICATION <br />GROUT BRAND NAME_bitilii <br />CONCRETE PEDESTAL BY DRILLER: Yoe101.11 No <br />OTHER ,,-.1'6'11/Die <br />44,3 Netno.e. <br />,1110(q -7- <br />DEPARTMENT USE ONLY <br />CABLE