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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 />ROMREFURDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br />(Complete In TapHMO <br />APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE VV0111( DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN <br />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 APPLE Flamdm ASP.. /HAy.120 CITY 1334:alal PARCEL 817E/APN# <br />OWNER'S NAME City Of B3M-1-Cn ADDRESS P.O. Bac 248 p„oN„ 838-4100 <br />CONTRACTOR V & W aillirrl ADDRES915 a33eerszn Ct. Rio Visizt, 720904 mow p707 374-2815 <br />SUE CONTRACTOR <br />ADDRESS UCS PHONE # <br />TYPE OF WELIJPUMP: O NEW WELL <br /> O REPLACEMENT WELL MONITORING WELL # <br /> <br />O OTHER <br />INSTALLATION <br /> <br />0 WELL SYSTEM REPAIR <br /> <br />O CROSS-CONNECT REPAIR VAPOR EXTRACTION WEUS 2 <br />0 New 0 Repel/ H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0 <br />(TYPE OF PUMPI <br />O OUT-OF-SERVICE WELL <br /> <br />O GEOPHYSICAL WELL <br /> <br />O SOIL BORING <br />0 DESTRUCTION: <br />INTENDED USE TYPE OF WEU. <br />INDUSTRIAL <br /> 0 OPEN eorrom <br />DOMESTIC/PRIVATE <br /> <br />Ea GRAVEL PACK/812/PM grallal- <br />o PUBUC/MUNICIPAL <br /> <br />0 DRIVEN <br />IRRIGATION/AG <br /> <br />0 OTHER <br />El MONITORING <br />APPROX. DEPTH <br />PROPOSED comernucropuonnurro METHOD: MUD ROTARY <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF WELL EXCAVATION 8 I <br />TYPE OF CASING/STEEL/PVC au <br />DEPTH OF GROUT SEAL 10-30 I <br />GROUT SEAL INSTALLED BY TrFrni <br />GROUT SEAL PUMPED: 0 Yee 0 No <br />LOCKING CHESTER BOX/STOVE PIPE <br />AIR ROTARY AUGER X <br />A <br />DIA. OF CONDUCTOR CASINO <br />DIA. OF WELL CASING 4" <br />SPECIFICATION IT <br />GROUT BRAND NAkensat oanEnt <br />CONCRETE PEDESTAL BY DRILLER: 0 Yee ON. <br />CABLE OTHER <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE VYORK 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 LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br />THIS PERMIT 19 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 THAI INlINE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CALIFORNIA. T CANT ADVALICE FOFI ALL MIMED INSPECTIONS AT 1200I 41115-3423. COMPLETE DRAWING AT LOWER AREA PRO <br />Signed X <br />PLOT PLAN 113/ew to Reels) Beele • to <br />I. NAMES 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 OUTUNF.8 AND LOCATION OF ALL EXISTING AND PROPOSED <br /> I. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATOS, DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br />Par wzrkplari dated 3/31/99 <br />f T Title L) Date <br />i‘‘t <br />...... .. <br />Applimtion Mewled By LitelAitnCC\ <br />DEPARTMENT USE ONLY <br />Oslo LI AI MI <br />Grout Impaction By <br />Destruction IrepectIon By <br />Comment•• <br />kj\.1*-k AnnarA"N Dote Pump Impeetlen By Dote <br />ACCOUNTING ONLY: AIDS FACE <br />PE CODES FEE INFO AMOUNT REMITTED CHECKS/CAIN RECEIVE!, BY DATE PER <br /> <br />MIT/SERVIarREQUELQ4UMBER INVOICE <br />3SOI i5/'(36' 11 I '356 I°° Lo )C1_ ) (-1(31A4ACZ"- 1/2-4/1 0 I CI O•t —7-- <br />C9\130 V 9°6 q <br />Pub Health Serv. Enviro. 173 (1/97)