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INTENDED USE <br />0 INDUSTRIAL <br />DOMESTIC/PRIVATE <br />PUBLIC/MUNICIPAL <br />IRRIGATION/AG <br />El MONITORING <br />APPROX. DEPTH <br />TYPE OF WELL <br />0 OPEN BOTTOM <br />ZI GRAVEL PACK/SIZE 1/3 sand <br />0 DRIVEN <br />0 OTHER <br />PROPOSED CONSTRUCTION/DRILUNG METHOD: MUD ROTARY <br />OCS-9-s <br />APPLICATION FOR WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEAL711 SERVICES <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 WON( DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />JOAQUIN COUNTY DEVELOPMENT TITLE. CHAPTER 9-1116.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBUC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR APN•1350 Baca ion Aw. crrY B3Cakn PARCEL SIZE/APHO <br />OWNER'S NAME City of E3calcn <br />ADDRE SS P.O. BDX 248 <br />PHONES 838-4100 <br />CONTRACTOR V&W Drillim ADORES li 5 at:ea-sal Ct.Rio Vistiticii 720904 rii0t4E i707 374-2315 <br />SUB CONTRACTOR ADDRESS IJCO PHONE it <br />TYPE OF WELUPUMPt El NEW WELL <br />0 INSTALLATION <br /> 0 New Et Repair <br />(TYPE OF PUMP) <br />REPLACEMENT WEU <br />0 WELL SYSTEM REPAIR <br />H.P. <br />OUT-OF-SERVICE WELL <br />rl MONITORING WELL E At 3 <br />CROSS-CONNECT REPAIR <br />DEPTH PUMP SET FT. <br />GEOPHYSICAL WELL <br />OTHER <br />El VAPOR EXTRACTION WELL <br />FIRST WATER LEVEL <br />SOIL BORING <br />0 DESTRUCTION: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF WELL EXCAVATION 8" <br />TYPE OF CASINO/STEEL/PVC RE <br />DEPTH OF GROUT SEAL 40 1 <br />GROUT SEAL INSTALLED BY Trernie <br />GROUT SEAL PUMPED: El Yee ID No <br />LOCKING CHESTER BOX/STOVE PIPE <br /> AIR ROTARY AUGER X <br />A <br />DIA. OF CONDUCTOR CASINO 0 <br />2 " DIA. OF WELL CASINO /3 <br />SPECIFICATION <br />GROUT BRAND NAME neat 02111Ent <br />CONCRETE PEDESTAL BY DRILLER: 0 Yoe 0 Ne <br />CABLE OTHER <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOFK WILL. BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AN <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 SUS-CONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: I CE FY THAT E PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF Li's- <br />CALIFORNIA. FOR ALL REQUIRED INSPECTIONS AT (2081 401-3423. COMPLETE DRAWING AT LOWER AREA PROVI D. <br /> OP <br />Stoned X TItlo <br />PLOT PLAN Prow 10 Scale) Seel* <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 OUTUNFII AND LOCATION OF ALL EXISTING AND PROPOSED <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. <br />Par TAWiplan dated 3/31/99 <br />te <br />4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />ck' <br />. ... • • • <br />....... : <br />DEPARTMENT USE ONLY <br />Applleetlen Accepted By (.1(C.,\AA Dote 112-61” — <br />Oreut Impaction By <br />Onstroction Inoneellon By <br />Co ntrnent <br />Del. Pump Impaction By Delo <br />ACCOUNTING ONLY: AIDE FACE <br />PE CODES FEE INFO AMOUNT REMITTED CHECKS/CAIN RECBVED BY DATE PERMIT/SERVICE REQUEST NIP ER INVOICE <br />5—051 $'&i'°° --t1 E 9-C6 ' °C.) li 0 )\Ct A-40a-, <br />SP\Ob \9:66tc, > <br />Pub Health Serv. - Enviro. 173 (1/97)