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DEPARTMENT USE ONLY <br />Area <br />PPLICATION FOR WELL/PUMP PER <br />SA. JAOUIN COUNTY PUBLIC HEALTH SACES <br />ENVIRONMENTAL HEALTH DIVISION <br />304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br />(209) 468-3420 <br />11011•REFUNDARE 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 WOW DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />JOAOUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />CuAa-triz- v s-c J 441 .) OB ADDRESS/OR APNS , '17.)C‘C-Ci..m4 CA PARCEL SIZEIAPNI <br />OWNER'S NAME DOW R 001 <br />CONTRACTOR A100 rolol Al Cs) ID It I LA- <br /> <br />VIGO S 1.11410...11 jr, 44-". 51S0 <br />ADDRESS ' C4 cot 95.. 33 PHONE <br />PO _ 707 3 '74 43 vo <br />AoonessflOX. .5.360 to NI 15,./k uct iIco19 PHONE <br />SUB CONTRACTOR ADDRESS UCS PHONES <br />- <br />TYPE OF WELL/PUMP: 0 NEW WELL 0 REPLACEMENT WELL 0 MONITORING WELLS 0 OTHER <br />0 INSTALLATION 0 WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELL <br />0 Now 0 Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br />(TYPE OF PUMP' <br />0 OUT-OF-SERVICE WELL 0 GEOPHYSICAL WEllS 0 SOIL BORING <br />0 DESTRUCTION: <br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS,,!..; 5,,o ;.,r ,404 <br />DIA. OF CONDUCTOR CASINO 20111004 0 <br />0 <br />E <br />3 <br />s <br />0 INDUSTRIAL <br />0 DOMESTIC/PRIVATE <br />0 PUBLIC/MUNICIPAL <br />0 IRRIGATION/AG <br />0 MONITORING <br />APPROX. DEPTH <br />0 OPEN BOTTOM <br />0 GRAVEL PACK/SIZE li 3 sAAH> <br />DIA. OF WELL EXCAVATION t 51 b s <br />TYPE OF CASING/STEE <br />,,,, 4 0 <br />-c DIA. OF WELL CASINO 2.- t p.a..4 <br />0 DRIVEN <br />0 OTHER <br />DEPTH OF GROUT SEAL 117 6 2: i 96 1 5 C A-I t C .% SPECIFICATION R <br />GROUT SEAL INSTALLED BY nal" ....., . c- GROUT BRAND NAME cr,1 ....,- <br />GROUT SEAL PUMPED: Dv... O N.. <br />LOCKING CHESTER BOX/STOVE PIPE <br />CONCRETE PEDESTAL BY DRILLER: 0Y.. ON. <br />PROPOSED CONSTRUCTION/DRILUNG METHOD: MUD ROTARY AIR ROTARY AUGER )(,,• CABLE OTHER <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE VVOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY OROINANCE9, STATE LAWS, AND RULES AND <br />REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW 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 APPUCANT MUST CALL 24 HOURS IN ADVANCE EL,,..711.1.0,it).-REOU/RED INSPECTIONS AT 12001 4803423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Stonol X Title • .//,' k • le"A'i‘/A/ /1' , ; A / e D.I. / <br />to PLOT PLAN (Draw to Boole) Scale <br />I. NAMES OF STREETS OR ROADS NEAREST TO on BOUNDING THE PROPERTY. <br />OUTLINE OF THE rnootmv, GIVING DIMENSIONS AND NORTH DIRECTION, <br />DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WAL.KS. <br />SA.oxr" <br />LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM on 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 />AoollcatIon Aetmoted By <br />Groot In•pootIon By <br /> <br />Do•Inomlon In•noollon By <br />Commont•: <br />fvklA1A1*,„ <br />Date Pomp Ineemetlen By Date <br />Dote <br />.ro NE.IA LaNaoz x r6L Vt.->( /7)Zfra4.14 <br />ACCOUNTING ONLY: AIDS FACS <br />PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />VI ..,....., <br />/ (/ 2 V <br />Pub. Health Serv. - Enviro. 173 (1/97)