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Cornroont•: AA, I-5. Le dt- <br />1/:)1‘i '/ '-e” 1-)6ci-. <br />ACCOUNTING ONLY: AIDS <br /> FACS <br />ept (i4 <br />,a- --:f <br />t"LICATION FOR WELL/PUMP PERMIT <br />SAN ..11% 'UIN COUNTY PUBLIC HEALTH SERV, ; <br />ENVIRONMENTAL HEALTH DIVISION <br />304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br />(209) 468-3420 <br />NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete in Triplicate) <br />APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />JOAOUIN COUNTY DEVELOPMENT TITLE. CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR APNE C ki,t4 '51* . CITY iev PARCEL SIZE/APNe '2•21- <br />OWNER'S NAME • ADDRESRZ ; t,( t 41 Y 3 2.-t' PHONE /I <br />CONTRACTOR AD RUM*" ••04- uciC5rCFC.1.7.21 PHONE 4V.- `i) <br />SUB CONTRACTOWTTrtprrb-"•-- GYe(3,-) brt- (‘`-_ .;>3on en ,,4.2'6'W:14-124 uc457 E•z2--1 PHONE <br />(I <br />TYPE OF WELL/PUMP: 0 NEW WELL 0 REPLACEMENT WELL 0 mo 5 RING WELL K PI OTHER - Kt.. pr.- 6 < ... .-, <br />0 INSTALLATION 0 WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELL S <br />0 Now 0 Repelr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br />(TYPE OF PUMPI <br /> <br />0 OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL I 0 SOIL nonmo <br /> <br />0 DESTRUCTION: <br /> <br />cAtte,—) v-4 ,L4 <br /> <br />A <br />D c <br />R <br />0 IRRIGATION/AO 0 OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br />0 MONITORING GROUT SEAL PUMPED: 0 Yee 13 No CONCRETE PEDESTAL BY DRILLER: 0 Y.. 0 No S . <br />APPROX. DEPTH LOCKING CHESTER BOX/STOVE PIPE <br />PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOEK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES. STATE LAWS, AND RULES AND-- <br />PEGULATIoNS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WOPK FOR <br />THIS PERMIT IS ISSUED, I SIIALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA. • CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE cERTIFIE <br />THE FOLLOWING: • I CERTIFY THAT IN PIE PERFORMANCE OF THE VVOM FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS 0 <br />CALIFORNIA. THE AP MUST ALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 120•I 4111-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Signod X Title Date /141t.ie <br /> <br />PLOT PLAN (Draw to Setae) Seele <br />NAMER 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. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, <br />DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. ON THE PROPERTY on ADJOINING PROPERTY <br />DEPARTMENT USE ONLY <br />Application Accepted <br />L "A ( / C --.5 Date 1 I 1 g (iPumyr Impaction By Date nrokrt Insp....lion By <br />OnetrIonilon Inspection By Date <br />PE CODES , FEE INFO AMOUNT REMITTED )ASH RECEIVED BY DATE INVOICE _ NUMBER <br />3 .5-0 i 89 — r — 7;i <br />Pub. Health Serv. - Enviro. 173 (1/97) <br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br />0 INDUSTRIAL 0 OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING <br />DIA. OF WELL CASINO <br />SPECIFICATION <br /> <br />El DOMESTIC/PRIVATE 0 GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC <br /> <br />PUBLIC/MUNICIPAL 0 DRIVEN DEPTH OF GROUT SEAL <br /> <br />Del. Area