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CONTRACTOR <br />.1267e LI C.) 1--1,417i."7 OWNER'S NAME <br />SUB CONTRACTOR 1//eiyucx <br />TYPE OF WELL/PUMP: 0 NEW WELL <br />0 INSTALLATION <br />0 Now 0 Repair <br />REPLACEMENT WELL <br />0 WELL SYSTEM REPAIR <br />H.P. <br />OUT-OF4TERVICE WELL <br />MONITORING WELL E <br />CROSS-CONNECT REPAIR <br />DEPTH PUMP SET FT. <br />GEOPHYSICAL WELL <br />OTHER <br />VAPOR EXTRACTION WELL It <br />FIRST WATER LEVEL <br />reow BORING <br />(TYPE OF PUMP/ <br />Lai 0 DESTRUCTION: <br />1/3 — <br />OTHER PROPOSED CONSTRUCTIONMERUNG METHOD: MUD ROTARY CABLE AIR ROTARY AUGER <br />to <br />4. LOCATION OF HOUSE SEWAGE DISPOSAL roam on PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />U. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />PLOT PLAN 11)row to goals) Scala <br />NAME OF STREETS OR ROADS NEAREST TO OR POUNDING 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 WAL(S. <br />o <br />Date <br />Application MY:WM By <br />(Pout Impaction By /4,111(•"-4.-4A. Dote/ OM/e ° Purnp InapectIon By <br />DEPARTMENT USE ONLY <br />APPLICATION FOR WELL/PUMP PERMIT <br />SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br />(209) 468-3420 <br />NOR-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />ICemolo(e he Triplicate, <br />APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT Amnton INSTALL THE WON( DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />JOAOUIN COUNTY DEVELOPMENT TRU, CHAPTER 9-1 1 1 5.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />C,„ 9-7---&eiz regt) PARCEL SIZEJAPNO <br />ADDRE9S,(971/ NA) y .o.e i 57-leA) PHONE <br />,9 7 g? <br /> A....2x,ns 6 il ,',4742-s- 7 — UCE PHONE 09:773 <br />ADOTIES13:21/6/461445 it-'-- UCE ?-es---F-1-. PHO‘E/ ,-.6k; '17 <br />0/e <br />JOB ADDRESS/OR APNE 7 .71/ 1.417./Y bR i 4.3)7/...41) <br />INTENDED USE <br />INDUSTRIAL <br />DOMESTIC/PRIVATE <br />o PUBUC/MUNICIPAL <br />IRRIGATION/AG <br />MONITOR/NO <br />APPROX. DEPTH <br />TYPE OF WELL <br />0 OPEN BOTTOM <br />0 GRAVEL PACK/SIZE <br />0 DRIVEN <br />0 OTHER <br />s-- <br />TYPE OF CASINO/STEEL/PVC <br />DEPTH OF GROUT SEAL <br />GROUT SEAL INSTALLED BY <br />GROUT SEAL PUMPED: 0 Yon <br />DIA. OF CONDUCTOR CASING <br />DIA. OF WELL CASINO <br />SPECIFICATION <br />GROUT BRAND NAME <br />O N. CONCRETE PEDESTAL BY DRILLER: D v.. 0 No <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF WELL EXCAVATION <br />LOCKING CHESTER BOX/STOVE PIPE <br />A <br />Li <br />I HEREBY CERTIFY THAT I ',AVE PREPARED THIS APPUCATiON AND THAT THE WORK WILL BE DONE /N 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: 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br />THIS PERMIT IS ISSUED, I !MALL 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 18 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CALIFORNIA.• THE APPUCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT ( I 40E4422. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />-> <br /> <br />Till. ' 6-;%C7'lc2( Date <br />ah06- i_acj.fs' nxy _Wp/ii:j/pth 1)/ee--77 - )tt) <br />Signed X <br />ACCOUNTING ONLY: AIDE 1 FACE <br />PE CODES FEE INFO AMOUNT REMITTED CHEC S ASH RECI3VED BY DATE INVOICE P REQUEST <br />36-0( ffi,- 431-- c,-) P-k_ loluktr" a... D 6 a-ct 2_24 t„, .....--) <br />Pub Health Serv. - Enviro. 173 (1/97) <br /> Date <br />v—tfre <br />Onatroction Impaction By <br />Commonly (7,0