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0.1.to /0/ <br />ilitt Pump IneoectIon By Dote <br />Delo <br />DEPARTMENT USE ONLY <br />ApplIcettort Accepted By LIYA <br />Grout In pectton By <br />Deetructlen Intrpectlon BE <br />Comment.: <br />APPLICATION FOR WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br />ENVIRONMENTAL HEALTH DIVISION <br /> <br />SEP 21 PH 1: 04 <br />(209) 468-3420 <br />NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />ICompleti In Triplicate) <br />APPLICATION IS HERE BY MADE TO THE BAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOFK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />JOAQUIN COUNTY DEVELOPMENT TITLE. CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION, <br />CITY r MICR_ SI7E/APNS /SD"- ogo - <br />o ADOREEE p... x- go • (.7 154,1 PII04 — <br />ADDRESS P.O. gOk 357 rs*, <br />ADDRESS 1.101 PHONE <br />JOB ADDRESS/OR AM, F S , •i"-E4 <br />OWNER'S NAME Te ?me-1 A106) <br />004 "reA I I I . (c • <br />MI CONTRACTOR <br />CONTRACTOR PHONE V07 —3/ —434X3 <br />TYPE OF WELLMUMP: 0 NEW WELL <br />0 INSTALLATION <br /> 0 N." 0 Rept* <br />(TYPE OF PUMP) <br />0 DESTRUCTION: <br />REPLACEMENT VVELL <br />WELL SYSTEM REPAIR <br />OUT-OF-SERVICE WELL <br />N. MONITORING WELLS 4A 11 e 9 <br />CROSS-CONNECT REPAIR <br />DEPTH PUMP SET FT. <br />GEOPHYSICAL WELLS <br />0 OTHER <br />VAPOR EXTRACTION WELL <br />FIRST WATER LEVEL <br />SOIL BORING <br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 1 0 <br />a INDUSTRIAL 0 OPEN BOTTOM , ,-, i DIA. OF WELL EXCAVATION e , <br />DOMESTIC/PRIVATE OGRAVEL PACK/SIZE' <br />I/ / <br />, i TYPE OF cAsmorsrEFurvc SrIn 4'0 . PVC.- <br />1:1 PUBLIC/MUNICIPAL 0 DRIVEN DEPTH OF GROUT SEAL Z '40 f <br />IRRIGATION/AG 0 OTHER GROUT SEAL INSTALLED BY "De .1 re". <br />IR1 MONITORING GROUT SEAL PUMPED: WY.. ON. <br />APPROX. DEPTH 1 0 Fe cf-- LOCKING CHESTER BOX/STOVE PIPE <br />PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER \ <br />A <br />DIA. OF CONDUCTOR CASING /1/4../114- <br />DIA. OF WELL CASING 0 <br />SPECIFICATION SC4 4-0 <br />GROUT BRAND NAME 790 ,144A Oe <br />CONCRETE PEDESTAL BY DRILLER:M.Yes EiNe <br />CABLE OTHER <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATION AND THAT THE WON( 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 IJCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br />THIS PERMIT IS ISSUED, I SHAL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: " I CErtTIFfJTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED. 1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CAUFORN1A.' T)4t APPUC MUST CALL 24 HOURS IN ADVANCE FOR ALL REOUMED INSPECTIONS AT 120111 401-S1123. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />SIgnotl X 44.1 <br />PLOT PLAN (Drew to Scale) Scale <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 OLITUNFS AND LOCATION OF ALL EXISTING AND PROPOSED <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WA1X8. <br />to <br />LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS, <br />LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />... <br />) <br />Dm. <br />ACCOUNTING ONLY: AIDS <br /> PACO <br />PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECEIVED BY DATE. PERMIT/SERVICE REQUEST NUFABER INVOICE <br />1 <br />,...-7 <br />b <br />• <br />ol <br />0 <br />I -Ai "Z-- /67/Y(7 0 .013.5.1 <br />sckooaoes - <br />Pub Pub Health Serv. - Enviro. 173 (1/97)