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APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WESER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES f YEAR FROM DATE ISSUED <br /> (Complete In Trlpksta) <br /> APPLICATION 18 HERE 6Y MAGE TO THE SAN JOAOtAN COUNTY FOR A PERMIT TO CONSTRUCT ANDI'OR INSTALL THE WORK DESCRIBED.TWO APPLICATION 18 MADE IN COMPLIANCE WITH SAN <br /> JOAGUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-111 5.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICEB.ENVIRONMENTAL HEALTH DIVISION. <br /> JOB AVORESSIOR APNS 3 1 0 Mount Diablo CRY Tracy <br /> PARCEL SIZElAPHS <br /> OWNER'S NAME Jack Thomson ADURE88 S/A PHONE 18 3 5-9 4 9 1 <br /> COMPACTOR_r+ Leita,-i Electric . Inc . AvmasP . 0 . Box 16 Banta uC,r453962 PHONEs835-2814 <br /> PUS CONTRACTOR ADDRESS LICe PHONE S <br /> TYPE OF WEUJPUMF- ❑ NEW WELL ❑ REPLACEMENT WM © MONITORING WELLS ❑ OTHER <br /> D INSTALLATION CI WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL s J <br /> Jet ❑Naw®Rmah H.P. 1— 1 /2 DEPTH PUMP SET 5 0 FT. FIRST WATER LEVEL 20 p <br /> (TYPE OF PUMPI <br /> -7 ❑ PUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELLs [j SOIL BORING S <br /> 1J DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION! A <br /> 13 INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION OW OF CONDUCTOR CASING D <br /> DOMESTK:RRIVATE ❑ORAVEL PACKISRE TYPE OF CASmamrFEUPVC VIA.OF WELL CASINO D <br /> ❑ PUBLICIMUMWAL 13 DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ IRIBGATIONIAG ❑OTHER GROUT BEAL INSTALLED BY OROUT BRAND NAME E <br /> ❑ MONITORING GROUT BEAL PUMPED: ❑Yee CIN. CONCRETE PEDESTAL BY DRILLER:❑Yw []No <br /> S <br /> AP X.DEPTH 66 LOCKING CHESTER BOX18TOVE PIPE <br /> S <br /> PROPOSED CONSTRUCTIONIDRILUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> 114PWRY CERTIFY THAT 114AVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAGUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND <br /> REGULATIONS OF THE SAN JOAOUIH COUNTY, HOME OWNER OR LICENSED 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 L.AW6 OF CALIFORNIA.' CONTRACTOR'B HIRING OR SUBCONTRACTMO MNATURE CERTIFtEe <br /> THE FOLLOWING: '1 CE .,HAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED.I SHALL EMPLOY PERSONS BURJECT TO WORKMAN'{COMPENSATION LAWS OF <br /> CALIFORNIA.' TINE 'P n UST CALL 21 F IN ADVANCE FOR ALL REGUIRWO INS TIONS AT(7081 440.3478. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Stoned X TRIO - Dar <br /> FLOT PIAN(Drew to Sodel 8/e10 "to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PPOPOS£D <br /> 7. OUTURE OF THE PROPERTY,GIVM DIMENSIONS AND NORTH L„RECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> S. DIMENSIONED OUTtW.8 AND LOCATION OF ALL EXIeTom AND PHOPOWED S. LOCATION OF WELLS WHTBN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUOINO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, ON THE PROPERTY OR AOJOINM PROPERTY. -q <br /> r .. ... <br /> 77 <br /> -PAYMENT:PAYMENT <br /> RECEIVED <br /> 3 1998 <br /> SAN JOAQUIN COUNTY <br /> - - — - _ Pl16LJC HEALTH SERVICES <br /> :ENWRONMENTAL'HEALTFiDNfSILJN <br /> b bMTsn ETI T�vsCE•O�n�•� <br /> AppAoeepted By Dole i3[cl I <br /> yea <br /> Grout Inepaetlon By ete P r p U»p—don BY <br /> O"tnwtlen Impection By / Dote <br /> COMMMO : -30 LJIS O (� S <br /> ACCOUNTING ONLY; AIDS FACT <br /> PE CODES FEE INTO AMOUNT REMITTED NECKS ASH RECEIVED BY DATE PERMIT1SEtVICE REOUEST NUMBER INVOICE <br /> 9 4ao Lb 3 D 1 (o <br /> S b- <br /> Ptib Health Serv.-EnvirO.173(1197) �`"� f <br />