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PARCEL SIZE/APNE <br /> PHONE E. <br />LICEP/0,1 PHONE I <br />Onetroctlen Impaction BY Atk-A.ve Dole (2Io 0 <br />Are* (_of 2 <br />Date <br />DII.q2--1)00 <br />Grout Inspection By Pump Inspection By <br />Comment.: <br />DEPARTMENT USE ONLY <br />Application Accepted By <br />Date 2 (2.1 0 0 <br />ADDRESS <br />CONTRACTOR <br />APPLICATION 19 HERE BY MADE TO THE SAN JOAOUIN <br />JOAQUIN COUNTY DEVELOTMJNE Tr . HAFT/, R .9-1, zfr <br />JOB ADDRESS/OR AM/ / , / r/Mbr/I ) cr„ • <br />OWNER'S NAME 11,7 . t ,1)r <br />0/11`11 kir t ADDRESS2 e21/( <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 />NOWREFUNDARLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complots In Ttlplkotel <br />COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />1 16.3 AND THE STANDARDS OF SAN JOACIUIN COUNTY PUBLICd EALTII SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />UCE PHONE I SUB CONTRACTOR <br />ADOTIES8 <br />INTENDED USE <br />INDUSTRIAL <br />DOMESTIC/PRIVATE <br />o PUBUC/MUNICIPAL <br />IRRIGATION/AG <br />MONITORING <br />APPROX. DEPTH <br />113 DESTRUCTIO <br />(TYPE OF PUMP) a <br />TYPE OF WELUPUMP: 0 NEW WELL <br />0 INSTALLATION <br />0 New 0 Repair <br />TYPE OF WELL <br />0 OPEN BOTTOM <br />0 GRAVEL PACK/812E <br />DRIVEN <br />0 OTHER <br />H.P. <br />OUT-OF-SERVICE WELL <br />iti <br />REPLACEMEIft WELL <br />0 WELL SYSTEM REPAIR <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF WELL EXCAVATION <br />TYPE OF CASINO/STEEL/PVC <br />DEPTH OF GROUT SEAL <br />GROUT SEAL INSTALLED BY <br />GROUT SEAL PUMPED: Dv.. 0 No CONCRETE PEDESTAL BY DRILLER: El Yet 0 Ne <br />LOCKING CHESTER BOX/STOVE PIPE <br />AIR ROTARY AUGER <br />DIA. OF CONDUCTOR CASING <br />DIA. OF WELL CASING <br />SPECIFICATION <br />GROUT BRAND NAME <br /> CABLE OTHER <br />El MONITORING WELL # <br />CROSS-CONNECT REPAIR <br /> <br />OTHER <br />VAPOR EXTRACTION WELL <br />FIRST WATER LEVEL <br /> <br />DEPTH PUMP SET FT. <br />GEOPHYSICAL WELLS <br />rOir <br /> <br />0 <br /> <br />SOIL BORING <br /> <br />8 <br /> <br />PROPOSED CONSTRUCTION/DOMINO METHOD: MUD ROTARY <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND 67 <br />REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR UCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br />THIS PERMIT PERMIT 18 ISSUED, I SHALL IT.EAPtOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA. CONTRACTOR'S HIRING OR RUB-CONTRACTING SIGNATURE CERTIFIES ., <br />*TH? IN ANC OF THE WOES( FOR WHICH THIS PERMIT IS ISSUED. 1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF ' THE FOLLOWING <br />CAUFORNIA/ T MU T <br />-. <br />IN VANCE FOR AU. REOUIR 181111t71094 AJ I I ASS-2423. CO PLETE DRAWING AT LOWER AREA PROVIDED - <br />Title , I-- CLI ig I/ 1.'-7 ( DEM 2/,170i, er (\ <br />PLOT PLAN (Draw te Scale) Boole <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 OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. <br /> <br />to <br /> <br />4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />Signed X <br />ACCOUNTING ONLY: I AIDE I FACE --..... <br />PE CODES FEE INTO AMOUNT REMITTED CHECKS/CASH RECEIVED BY DATE PEFIMITISERVICE REQUEST NLRdBE INVOICE <br />27 V bC)6.53' 60 e2-- 77 2— _.......--- <br />Pub Health Serv. - Enviro. 173 (1/97)