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FIRST WATER LEVEL <br />OTHER VAPOR EXTRACTION WELL <br />jo•44 <br />REPLACEMENT WELL 0 WELL SYSTEM REPAIR H.P. CROSS-CONNECT REPAIR MONITORING WELL I <br />DEPTH PUMP SET FT. <br />TYPE OF WELL/PUMP; 0 NEW WELL <br />0 INSTALLATION <br /> 0 Now 0 Repair (TYPE OF PUMPI <br />0 DESTRUCTION. <br />Vil4:11. BORING OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL <br />DIA. OF CONDUCTOR CASING DIA. OF VVELL CASING SPECIFICATION <br />CONSTRUCTION SPECIFICATIONS DIA. OF WELL EXCAVATION 2 I/V • TYPE OF CASING/STEEL/PVC DEPTH OF GROUT SEAL Ci\T Fl <br />CONCRETE PEDESTAL BY DRIU_ER! 0 Yoe IlEt< <br />GROUT SEAL INSTALLED BY GROUT BRAND NAME D GROUT SEAL PUMPED: 0Y.. PIT; LOCKING CHESTER BOX/STOVE PIPE <br />to PLOT PLAN (Draw to Boole) Boole I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. OUTLINE OF THE PROPERTY, WINO DIMENSIONS AND NORTH DIRECTION. DIMENSIONED OUTUNES AND LOCATION OF ALL EXIST/NO AND PROPOSED STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. <br />0/6 /1te <br />ORIGINAL <br />OWNER'S NAME az....5 ,A ,„:40(--x.„7„. ,11-64-At Z-1.10?-1 <br />CITY ZA <br /> ADDRESS -1° 7g- ef (• PHONES <br />ORAD D 6 Ed6A)titeviViii ea-4 T'AZ ADDRESS 10t5 .14.1;Isch 7PHONE I/ /0:16? CONTRACT <br />aigg 6/5 5 . 74‘" 51/1.24(4... '1756' • f3eg PHONE :52 5/- *53 <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 />(Complete la Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1116.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR AM* 4 j-t-A e_fie) ceip PARCEL SIZEJAPNI <br />INTENDED USE INDUSTRIAL DOMESTIC/PRIVATE PUBUC/MUNICIPAL IRRIGATION/AG <br />Igir.4)NITORING APPROX. DEPTH <br />TYPE OF WELL 0 OPEN BOTTOM 0 GRAVEL PACK/SIZE 0 DRIVEN 0 OTHER <br />2-Q7 rr <br />/VA <br />,A) <br />PROPOSED CONSTRUCTION/DIELUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORE WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND tit, REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING! 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED, I MALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALWORNIA. CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: ' I CERTIFY THAT IN THE PERFORMANCE OF THE WORE FOR WHICH THIS PERMIT 18 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.• THE APPLICANT MUST 24 HOLSIs1I ADVANCE FOR ALL REQUIRED INSPECTIONS AT 120111 400-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Pe. lid.6eIr/(9 irtieacrer fildV6g_ Dote 04--C(7 , <br />Date <br />/-Q-zr i(-eD:•;* /4c. <br /> <br />Applicellon Accepted By <br />Grout Impaction By <br /> <br />i.e Destruction Impair By <br />C Comment e ! <br />DEPARTMENT USE ONLY <br />Purnp tritpection By <br />ACCOUNTING ONLY: AIDS FACO <br />PS CODES CODES ,AFEE INTO AMOUNT REMITTED CHECKS/CASH RECEIVED BY DATE PERIM/SERVICE REQUEST NUMBER ..... INVOICE <br />3601 an ii / /2- 175ivi <br />Pub Health Serv. - Enviro. 173 (1/97) <br />4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED EXPANSION OF SEWAGE DISPOSAL SYSTEMS, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. ON THE PROPERTY OR ADJOINING PROPERTY.