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L- <br /> APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 96201368 <br /> (209) 468.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Compl.ie In Triplkete) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANWOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-11 1 S.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH IMOSSION. <br /> JOBADDRESSIORAPNE 27 480 N. Horseshoe CIT„ Clements , Ca _ PARCEL SIZEIAPN11 6 .5/bare <br /> OWNER'B NAME ,John Teresi ADDRESS P.O. BQX 81 9 f Lodi a,,ONE,r <br /> CONTRACTOPurviance Drillers, Inc. ADDREsf•oBox 64 , Linden ... 377923 PHONE# 887-355 <br /> SUB CONTRACTOR n/ a ADDRESS UC! PHONE I <br /> TYPE OF WI5UlPLIMP: fr-��Ld NEW WALL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER_ <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXT.RACTION WELLf ,J <br /> ®Naw❑mveir H.P. DEPTH PUMP SETZ#0 FT- FIRST WATER LEVEL (3 <br /> RYPE OF PUMP) <br /> ❑.OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SO4.BORING 8 <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION! A <br /> ❑ INDUSTRIAL 10 OPEN BOTTOM DIA.OF WELL EXCAVATION 1 9 Ji A.OF CONDUCTORCASING na 0 <br /> ❑ DOMESTICIPRIVATE ❑GRAVEL PACKISIZE TYPE OF CASINGISTEEUPVC _ steel <br /> pp t e e l DIA.OF WELL CASING 12 3 4 D <br /> 1:1PUBLICIMUNICIPAL 11 DRIVEN DEPTH OF GROUT SEAL O 0 I i SPECIFICATION • 1 88 R <br /> ® IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED by PDI GROUT BRAND NAME E <br /> ❑ MONITORING d GROUT SEAL PUMPED: 13Yaa ❑No CONCRETE PEDESTAL BY DRILLER;11Y. ❑No 5 <br /> APPROX.DEPTH �3�1r ;) G�=�{ -�L J1 LOCKING CHESTER BOXISTOVE PIPE S <br /> PROPOSED CONNTRUCTIONIVaLUNG MITH6: I ROTARY_ AIR ROTARY AUGER CABLE_ OTHER <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILT,BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES ANC <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICI <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSQNB SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIER <br /> THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 10 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAWS COMPENSATION LAWS OI <br /> CALIFORNIA.' THE APPLICANT ALL 24 HOURS IN ADVANCE FOR ALL W al IRED INSPECTIONS AT 12011114".3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Slonad x +2�•� T,t,e Corporate Secretary D 3/17/9 7 <br /> PLOT PLAN Ibraw to Sema)SeW to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. �^ 4. LOCATION OF ROUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, - <br /> 3. DIMENSIONED OUTUNFS AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT, <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WAU". ON THE PROPERTY OR ADJOINING PROPERTY, J <br /> � lI <br /> IL <br /> CD <br /> DEPARTMENT USE ONLY ''''} f <br /> Application Accepted By_ Date �' -~� � . f <br /> kea <br /> Oreut Impeetlen By � /ff i� t% Dae ��J�+xa/�� pump Inspection By'I � � bat <br /> Deatru tion lnapectlon By '--, ii <br /> Date <br /> Comments <br /> ACCOUNTING ONLY; AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# H RECEIVED BY DATE PERMITIS VI T NUMILC R INVOICE <br /> rL. I')"� I./ <br /> 6 '114 <br /> s 5 � <br /> S111-1,7110 US <br />