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MAR 1 6 1999 <br />' I V • <br />el I I (pR 4 e 6 1 I 0 0 4 - <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-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />ICemplets hi Triplicate' <br />APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WON( DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WT111 SAN <br />JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 50-1 ii 5.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR APP/8 /..:2-0 7 rA <br />OWNER'S NAME r c ADDRESS <br />CONTRACTOR V tit° 11"a:fawn <br />SUB CONTRACTOR Vtp e-A I Y.11. L.--°3$(2-C t bi <br />TYPE OF WELL/PUMP: El NEW WELL 0 REPLACEMENT WELL 0 MONITORING WELLS <br />0 INSTALLATION 0 WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR <br />0 New 0 Remit H.P. DEPTH PUMP SET FT. <br />(TYPE OF PUMP1 <br />0 OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELLS <br />0 DESTRUCTION: <br />0 OTHER <br />0 VAPOR EXTRACTION WELLS <br />FIRST WATER LEVEL <br />El ROIL BORING <br />0 <br />CITY <br />PARCEL SIZE/APN/ <br />)0 7 77::‘+41-toNE <br />CS <br /> <br />• <br /> <br />INTENDED USE TYPE OF WELL <br />1:1 INDUSTRIAL 0 OPEN BOTTOM <br />1:11 DOMESTIC/PRIVATE 0 GRAVEL PACK/SIZE <br />0 PUBLIC/MUNICIPAL 0 DRIVEN <br />IRRIGATION/AG 0 OTHER <br />I.O <br /> A OX. DEPTH <br />NITORING <br />PROPOSED CONSTRUCTION/DRILUNO METHOD: MUD ROTARY <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING <br />TYPE OF CASING/STEEL/PVC DIA. OF WELL CASINO <br />DEPTH OF GROUT SEAL SPECIFICATION <br />GROUT SEAL INSTALLED BY GROUT BRAND NAME <br />GROUT SEAL PUMPED: El Yes 0 No CONCRETE PEDESTAL BY DRILLER: 0 Too O N. <br />LOCKING CHESTER BOX/STOVE PIPE <br />AIR ROTARY AUGER CABLE OTHER <br />A <br />0 <br />0 <br />R <br />S <br /> ..P.1 I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCAT1ON AND THAT THE WOFK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES. STATE LAWS, AND RULES AND <br />REGULATIONS OF THE SAN JOA COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE VVOPK FOR WHICH <br />THIS PE IT IS ISSUED. 1 SITA NOT EtOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALWORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTIN0 SIGNATURE CERTIFIES <br />THE FO • 1 CERTI THAT IN 1E PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED. I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF...:. <br />CALWO APPUCA MUST CA 24 HOURS IN ADVANCE FOR ALL REOUIRED INSPECTIONS T (2041 44*-.1421. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> <br />Date ,...r/4**/ J .., e''...". TC C>4.../C- jc.- -7 <br />Title <br />Z.) <br />-..% OT PLAN (Drew to Seidel gore <br />I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. <br />OUTLINE OF THE PROPERTY. GIVING DIMENSIONS AND NORTH DIRECTION. <br />DIMENSIONED OUTUNFIS AND LOCATION OF ALL EXISTING AND PROPOSED <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. <br />Warted X <br />1. <br />4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR morass) <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />S. LOCATION OF WELLS VOTTH04 RADIUS OF ONE HUNDRED FIFTY FT. <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br /> <br />. . . ....... . <br />....... • • <br />DEPARTMENT USE ONLY <br />Date 3( 7-2-1i1 <br />SZ 0,,a ctetCP <br />Ares <br />ct,122,1:111**P1J3n118.41vs:CIIAA/2:711V(Pn y +C. Date Date <br />Lit, lq — <br />S 1 3 1 9 - ctiyi, ',at-€.1-'3 - HA tvt--t---)--S-` Dee <br />thaelo <br />Applleatlen Accarted By <br />Grout Impaction By <br />Deetmaren IneneetIon By <br />Cencrente: PQ/VIAAA_A— m4,,sieg <br />ACCOUNTING ONLY: AIDS FACS <br />PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />35c> tchao 103 / tLQ 3/r(17 0 t b S-1 <br />(0 C) _, <br />Pub Health Serv. - Enviro. 173 (1/97)