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\-r <br />Y1/42-- <br />DSPR1MNT USE ONLY <br />J(e p Impaction By Doe <br />Del. gm/14/ ( Ares <br />Date <br />AppllamIle. Accepted By <br />Grout lytwootIon By <br />Deetrteetien Inepection By <br />COmmelite: <br />ACCOUNTING ONLY: AIDE FACE <br />PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH P El BY DATE PERMIT/SERVICE REQUEST NUFASER INVOICE 1 <br />gff • C° /671,3 ,, Cr 1 1 Si30 20 2 :f6 <br />_ --- <br />,,,, CS 9\602o1r/ 5 <br />Pub Health Serv. - Enviro. 173 (1/97) <br />• <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 />RON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete In Triplicate) <br />APPLICATION 19 HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. T1119 APPLICATION 18 MADE IN COMPLIANCE VVITII SAN <br />JOAOUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1 115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR APNO 23 I 5 -- 21- 1 fic; (10 <br />CfTY /4•24 PARCEL SIZEJAPNI /Z-57C-JC / 7 - <br />CONTRACTOR / <br />OWNER'S NAME Sl c'r e 1/e7/e-7717-1 <br />ADWIESS 23 Z //e 4 ve.i S-4-c`0140NE <br />ADDRESS P o /5"er?..4- 151-'/UCA 7 Z41%; 4/ pctoptE g 7,2 0 -3 _ 8- <br />SOB CONTRACTOR <br />ADDRESS <br /> <br />UCII PHONE I <br />TYPE OF WELL/PUMP: 0 NEW WELL 0 REPLACEMENT WELL or MONR WWII WELLS 2 0 OTHER <br />0 INSTALLATION 0 WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELL F J <br /> 0 Now 0 Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL o <br />(TYPE OF PUMPI <br />0 OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELLS 0 SOIL BORING g <br />0 DESTRUCTION: <br />INTENDED USE TYPE OF WELL <br />INDUSTRIAL <br /> 0 OPEN BOTTOM <br />DOMESTIC/PRIVATE <br /> <br />al GRAVEL PACK/SIZE <br /> <br />/ <br />PUBLIC/MUNICIPAL <br /> <br />0 DRIVEN <br />IRRIGATION/AG <br /> 0 OTHER <br />MONITORING <br />APPROX. DEPTH 610 o ' <br />I HEREBY CERTIFY THAT I HAVE PREPARED TN APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND <br />REGULATIONS OF THE SAPj JOAOUIN C ME OWNER OR UCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: I CERTIFY THAT IN THE PEWORMANCE OF THE WOW FOR WHICH <br />THIS PERMIT IS ISSUED, Ma NO PLOY WIONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORMA. CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: SRTIFY T T N fl RFORMANCE OF THE WOW FOR WHICH THIS PERMIT 18 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CAUEOW41.4." PPUCANT LL 24 HOURS IN ADVANCE FOR ALL REOUIRED INS HOPIT 12011 4SS-.11121. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />TN. r Dam I <br />PLOT PLAN Ithina to Seidel Scale ' to <br />I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM on PROPOSED <br />OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED <br /> <br />5. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br />GROUT SEAL PUMPED: aim 0 No CONCRETE PEDESTAL BY DRILLER: 0Y.. 0 No <br />LOCKING CHESTER BOX/STOVE PIPE <br />PROPOSED CONSTRUCTION/WRUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br />CONSTRUCTION SPECIFICATIONS A <br />DIA. OF WELL EXCAVATION 8 DIA. OF CONDUCTOR CASINO /-*/./-,--4 0 -.......- <br />TYPE OF CASING/STEEL/PVC -C. (-1., L/c. " C DIA. OF WELL CASINO 2. o (Ssi <br />DEPTH OF GROUT SEAL 0 - 23 C.) 41- CI - /Q C9 SPECIFICATION R <br />)1 <br />GROUT SEAL INSTAU_ED BY L'.'4../- 14.1-.,,, - .itiF101.17 BRAND NAME E <br />-Z.-, <br /> <br />$ <br />i1-?•59 -