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EAST MUNFORD AVENUE I <br />\ 6 <br />APPLICATION FOR WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br />(209) 468-3420 <br />NON-REFUNDARLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete hi Triplicate) <br />APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. TIIIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1 115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR AM/ 14-\) evt.rt, CITY s-fcc,(1-tol PARCEL SIZEJAPNO <br />OWNER'S NAME C-' A Fr-, o It.,Itir.s.. s ADDRESS 0 C I) C-11. (:.) °N CI,. 5 ii:-.1 LI i c .f:., . ? ti•''ci PHONES <br />CONTRACTOR 4'— A- s :, c, c.:(1A-e. V,A_E___ ADDRESS l2s0C c-,&41.4% L4 4 ir- UCff <br />SUB CONTRACTOR Q 4. A ,-. k.k .A-S) ADDRESS i C &K St. k.c.) \LAC UC/ -12clo-t <br />PHONE • 51-1 - 2,L24 <br />PHONES 7 P-(- 24(5 <br />0 REPLACEMENT WELL <br />0 WELL SYSTEM REPAIR <br />H.P. <br />0 OUT-OF-SERVICE WELL <br />tit/MONITORING WELLS 3 0 OTHER <br />CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELL <br />DEPTH PUMP SET FT. <br />GEOPHYSICAL WELLS <br />FIRST WATER LEVEL <br /> <br />0 SOIL SWUNG <br /> <br />TYPE OF WELL/PUMP: ,"NEW WELL <br />0 INSTALLATION <br />o Now 0 Repair <br /> <br />(TYPE OF PUMPI <br /> <br />0 DESTRUCTION: <br />A <br />0 <br />INTENDED USE <br />INDUSTRIAL <br />DOMESTIC/PRIVATE <br />PUBUC/MUNICIPAL <br />CI IRRIGATION/AG <br />'MONITORING <br />APPROX. DEPTH <br />GROUT SEAL INSTALLED BY <br />GROUT SEAL PUMPED: 0 Y.. CINo <br />DIA. OF CONDUCTOR CASINO NltA <br />DIA. OF WELL CASINO <br />SPECIFICATION <br />GROUT BRAND NAME ki.L1100.‘11, <br />CONCRETE PEDESTAL BY DRILLER: El Yoe NigNo <br />TYPE OF WELL <br />0 OPEN BOTTOM <br />0 GRAVEL PACK/812E <br />o DRIVEN <br />El OTHER <br />CONSTRUCTION SPECIFICATIONS . <br />DIA. OF WELL EXCAVATION <br />TYPE OF CASING/STEEL/PVC p <br />DEPTH OF GROUT SEAL <br /> toier-5-` <br />bo <br />LOCKING CHESTER BOX/STOVE PIPE <br />PROPOSED CONSTRUCTION/DRILUNO 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 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 />CAUFORNIA.- THE APPUCANT MUST CAU. 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 120111 4011-3421. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Storm/ X kaiiniev„ LTitle Date <br /> <br />PLOT PLAN (Dun./ to Soolol Scale <br />NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. <br />OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. <br />DIMENSIONED (ATTUNES AND LOCATION OF ALL EXISTING AND PROPOSED <br />STRUCTURES, as 0/11111111 DRIVEWAYS AND WALKS. <br />LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />LOCATION OF WELLS INTTION RADIUS OF ONE HUNDRED FIFTY FT. <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />to SCALE IN FEET 1=2O <br />0 <br />I- <br />uJ< LLJ — Z ,c; 6 oc, <br />w > < <br />n 4 cf, 0 0 u_ z <br />UDO— (-) in 0 <br />1—a_ vp (r) <br /> <br />Li <br /> <br />*5?s- /9C A,. c27,5'4, <br />Delo <br />(7( <br /> <br />cald NW 7 - 2.- 0 h C2 f-t otoo.-c 4-1:1 <br />V <br />ACCOUNTING ONLY: AIDS PACO <br />PE CODES FEE INFO AMOUNT REMITTED ap ASH RECEIVED BY DATE PERIMIT/SERVICE REQUEST NUMBER INVOICE <br />39)) ?I - q ' /S'1 c.o q /z-'h' <br />S10,601(5 <br />Pub Health Serv. - Enviro. 173 (1/97) <br />MIN <br />Grout Inspee Sy <br />Appllastlen Acto4 By r <br />/- /0 <br />rusisersonwilF4st <br />DEPARTMENT USE ONLY <br />Pump Inopeetion By