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0 <br />15 5 <br />E 6)• <br />E- I rs <br />Date Pump Inspection By <br />DEPARTMENT USE ONLY <br />Application Accepted By <br />Grout Inspection By <br />Date <br />Date Area <br />Data <br />APPLICATION FOR WELL/PUMP PERMIT <br />JOAQUIN COUNTY PUBLIC HEALTH SERVICL <br />ENVIRONMENTAL HEALTH DIVISION <br />P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201-308 <br />(209) 468.3420 <br />NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />OWNER'S NAME <br />CONTRACTOR iiiiik. Ge-4)5C4.Iim.al a kC_ ADDRESS 1,1* 6- boost )1" efrs.6.41Aait MID ,I.,:stisAt z.,,,,H7 oNE , ki-----i-A4-7100 <br />SUB CONTRACTOR p. <br />JOB ADDRESS/OR APN0 'JO .7 .5;.; (AS( Atotrovv,.. 07r-e-Q- CITY 51:11) CLIVIll PARCEL SIZE/APN0 1 t 0 ,ek 5 O) <br />JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1 1 1 5.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <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 />6ett e• . f- (,,z• i tlit IN_ <br /> <br />dello Ceruc“i4e- —.7c--T-kal:,) ADDRESS t7 0 . OW 600e 5*Ce-t/Z.).1 (tit PHONE i '4)44 ' It6 '5;4,1 <br />i) <br /> <br />' lit„„ 7 ADDRESS Y5-0 04. e /2 1 Kiri) ((lg. 2 Z.- LIC 0 .4 Si PHONE 0 5 .10 .3t3 -.511.0 <br />(Complete in Triplicate) <br />1 <br />TYPE OF WELL/PUMP: O NEW WELL <br /> O REPLACEMENT WELL <br /> O MONITORING WELL 0 <br /> O OTHER <br />INSTALLATION <br /> El WELL SYSTEM REPAIR <br /> O CROSS-CONNECT REPAIR <br /> O VAPOR EXTRACTION WELL S <br />(TYPE OF PUMP) <br /> 0 New 0 Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br />0 <br />0 DESTRUCTION: <br />OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL k SOIL BORING ? 6-CeeyseAle- 110-'14 <br />(rNii, +21:h 0teti te ..;/) <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 />,OTHER 51 t ksj cS <br />4-0 <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF WELL EXCAVATION <br />TYPE OF CASING/STEEUPVC <br />DEPTH OF GROUT SEAL <br />GROUT SEAL INSTALLED BY <br />GROUT SEAL PUMPED: El Yes 0 No <br />LOCKING CHESTER BOX/STOVE PIPE <br />DIA. OF CONDUCTOR CASING <br />DIA. OF WELL CASING <br />SPECIFICATION <br />GROUT BRAND NAME <br />CONCRETE PEDESTAL BY DRILLER: 0 Yes 0 No <br />A <br />0 <br />LI <br />PROPOSED CONSTRUCTION/DRILIJNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER e msh <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW 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 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 WOW FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CALIFORNIA." TH APPLICANT MUST CALL 24 HO IN ADV NCE FOR ALL REQUIRED INSPEC_TI(ON4.41AT 11209) 4441-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Signed X <br />i <br />d-•-•., <br />, -7 t7.--ttlfri fi Title <br />G_4/i .sr <br />Data 7/1(M) <br />PLOT PLAN (Draw to Scale) Scale / I 1 - to 410 -rt. <br />NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <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 />Yticrsoikt ST4E- <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />5. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />USTs, <br />• <br />Destruction Inspection By <br />Comments: <br />PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />35o 1 4 3 9' -7-7 o (6 Nitc6131 -7. 21@.9- 01 3 19 <br />----