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JOB ADDRESS/OR AM* 15 -2. E t- 0 0 eAr, 0 <br />CITY 5-roctc-ror..1 <br />Dela DosetrtoetIon Inspection By <br />Commerils, —71,“() <br />APPLICATION FOR WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ORIGINAL 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 In Triplicated <br />APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WTTII SAN <br />JOAQUIN COUNTY DEVELOPMENT T)TLE, CHAPTER 9-1116.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />PARCEL SIZEJAPN* <br />17.4)5E-shu-F-- CA 75.4i/ <br />OWNER'S NAME "TO S CIP YvtikYLKS-TINLC:, ADDRESS 1380 1-6111D P-c>Sur5 12-0 FtKINE 17/6 -774 ^7..c/ 0 <br />Po SoK 336 CS7- cti / LICl/ 7/00.1 I PHONE /10-7 374-4-3e0 CONTRACTOR \ArCODWAS-D 170.11—LANIG. ADDRESS 1210 No is-ro. CA. <br />SUB CONTRACTOR ADDRESS IJC* PHONE <br />XMONITORING WELL it MIA/ •"/ -2.-3 —4-0 OTHER REPLACEMENT WELL <br />WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELL I <br />H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br />OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL * <br />TYPE OF WELL/PL/MP: 0 NEW WELL <br />0 INSTALLATION <br />0 N. RepeIr <br /> <br />(TYPE OF PUMP) <br /> <br />.A,Y\ <br />0 <br />0 SOIL BORING e7 3 <br />0 DESTRUCTION: <br />TYPE OF WELL <br />0 OPEN BOTTOM <br />X3RAVEL PACK/SIZE it. 3 <br />0 DRIVEN <br />0 OTHER <br />INTENDED USE <br />INDUSTRIAL <br />DOMESTIC/PRIVATE <br />PUBLIC/MUNICIPAL <br />0 IRRIGATION/AO <br />X MONITORING <br />APPROX. DEPTH <br /> 5-o FT <br />CONSTRUCTION SPECIFICATIONS A cc) <br />DIA. OF WELL EXCAVATION 2> - 114EL.I DIA. OF CONDUCTOR CASINO D (-- <br />TYPE OF CASING/STEEL/PVC NC-- 2_ - INICH <br />R <br />0 <br />GROUT SEAL INSTALLED BY .1.17.-F-Vnte.- GROUT BRAND NAME E <br />GROUT SEAL PUMPED:,'... ON. CONCRETE PEDESTAL BY DRILLER: 0 Y.. ON. <br />LOCKING CHESTER BOX/STOVE PIPE <br />DEPTH OF GROUT SEAL CIE-liRecil-r <br />DIA. OF WELL CASINO <br />SPECIFICATION <br />PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATION AND THAT THE WORE WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND <br />REGULATIONS OF THE SAN JOAOUIN 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 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 THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CALIFORNIA.' THE A ANT UST CALL 24 HOURS IN ADVANCE FOR ALL REGUIRED INSPECTIONS AT 12011) 4441-7423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Stoned X Cc.,c2-C>c...2.4-17E Tido /7124).s f Cfr MAPJA 4F/2_ <br /> <br />Date <br /> <br />PLOT PLAN Ow, to ScaloI Etc.!' IN • to 4-0 pç <br />I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. <br />ERMINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. <br />DIMENSIONED 00TUNFS AND LOCATION OF ALL EXIST/NO AND PROPOSED <br />STRUCTURES. INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WAL/C5. <br />LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />IL LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br /> <br />5ee <br />/0-zot (Yr <br />DEPARTMENT USE ONLY <br />Grout Impaction Sy re‘' Data Pump InepectIon By <br /> Date a -5 99 0‘, J/Application Accepted By <br />ACCOUNTING ONLY: AID* FACE <br />PE CODES FEE INFO AMOUNT REMITTED CHECK/MASH RECEIVED BY DATE POIMIT/SERVICE REQUEST NUMBER INVOICE <br />356 I 1\11AJ R41 c(*).5 / C,k- /1-/i <br />41 A / 40 A ° — <br />s V \O 0 P ()" <br />Pub Health Serv. - Enviro. 173 (1/97)