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X MONITORING WELL it tY1u).-111‹0 OTHER <br />CROSS-CONNECT REPAIR <br />DEPTH PUMP SET FT. <br />VAPOR EXTRACTION WELL <br />FIRST WATER LEVEL <br />REPLACEMENT WELL <br />WELL SYSTEM REPAIR <br />H.P. <br />PE CODES <br />APPLICATION FOR WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201-388 <br />(209) 468-3420 <br />NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete in Triplicate) <br />APPUCATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPUANCE WITH SAN <br />JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1 115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION <br />JOB ADDRESS/OR AM* CITY .5 1-00X-too PARCEL SIZE/APN* <br />ADDRESS r.00I-Ci PHONE #3'( .„, <br />ADDRESS I cu I 5f 64-4.:.6- 1011 LIC/I PHONE * 3 I L <br />ZL1 , -7, <br />PHONE St 1.-1 PS / I <br />OWNER'S NAME K:vk, L cI .Re-c-x-prt <br />CONTRACTOR 5rn n CO)111,1 e tell <br />SUB CONTRACTOR 3 pe.t...-crU Al i----er() to Oct 11 C 6. ADDRESS 2:24.5—(P., ICA 1A-Xt--/TI z <br />TYPE OF WELL/PUMP' I 'NEW WELL <br />0 INSTALLATION <br />0 New 0 Repair <br />(TYPE OF PUMP) <br />0 DESTRUCTION: <br />OUT-OF-SERVICE WELL GEOPHYSICAL WELL it <br /> <br />SOIL BORING <br /> <br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS i i A <br />0 INDUSTRIAL 0 OPEN BOTTOM <br />G,, <br />DIA. OF WELL EXCAVATION /3 DIA. OF CONDUCTOR CASING 141046. D <br />1:1 DOMESTIC/PRIVATE gGRAVEL PACK/SIZE Z112_, TYPE OF CASING/STEEL/PVC 1-10 PVC- DIA. OF WELL CASING D <br />0 PUBLIC/MUNICIPAL b DRIVEN DEPTH OF GROUT SEAL Z. el SPECIFICATION 44C i? <br />0 IRRIGATION/AG 'OTHER GROUT SEAL INSTALLED BY t( ')'V GROUT BRAND NAME E <br />%MONITORING GROUT SEAL PUMPED: CI Yea 0 No CONCRETE PEDESTAL BY DRILLER: 0 Yee 0 No <br />APPROX. DEPTH 18 c--t LOCKING CHESTER BOX/STOVE PIPE I L.- <br />PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR TARY AUGER X' ROTARY CABLE OTHER <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND <br />REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR UCENSED 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 WOW FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CALIFORNIA.- THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12091449-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />SIOnocl X 90 cuktALe— 740-YY1-4/-12j Title 1-7,-„,s1 C 5fei s ()I t 1— <br />NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />PLOT PLAN (Draw to Sca)e) Scale I " to 0 L' <br />le i <br />Date 4 <br />OUTUNE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />DIMENSIONED OUTUNES AND LOCATION OF ALL EXISTING AND PROPOSED 5. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br />\JIN1 <br />W <br />0 <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />Comments: <br />5 .76 <br />54/44.4."17117 DEPARTMENT USE ONLY <br /> Pump inspection By <br />7Citve_ 4.47 <br />Data <br />Date " <br />D.,.8Y1F—Y5 Ares <br />I FACE <br />FEE INFO <br />DATE PERMIT/SERVI RECK/ T <br />OA 6E) <br />AMOUNT REMITTED CHECKO/CASH <br />0044)7' <br />RECEIVE Y <br /> <br />INVOICE <br />S.(1\ 6, 60 6`) <br />ACCOUNTING ONLY: I AIDE