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SMR\ dum%dui19 %owuna T ruow%, nCAL111 JCr1VIRvCJ <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 JOT WEBER AVENUE, STOCKTON, CA 91Jwdw'3 <br /> (209) 468-3420 <br /> j NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> (Compl$t$In Triplicate) <br /> APPLICATION 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 COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVI81L0N. <br /> JOB ADDRESSOR APN/ 2 (o S J o 1 ,4/v I-/"r M/�/`0 A-p Cl/TY �/� me J h /� r PARCEL SIZE/APN# 2 <br /> OWNER'S NAMEE�,/rMA. nAi-F2F D P6 MR G ADDRESS96+S w �1/�' L�/'T /Z✓C. rryT��J PHONE <br /> CONTRACTOR •• C-'r TI 4ZMR-T DA(LL/A/6 ADDRE853z33�yF. ITZ6ffl`,44�QND7�cf S4 l9 PHONE 6i (0 <br /> SUB CONTRACTOR ADDRESS r C(o,`/�Vr,� rsT`UCI PHONE <br /> TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL MONITORING WELL 914 L) 7 IO �OTHER to-ni�f} <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR r ❑ VAPOR EXTRACTION WELL 01 J J <br /> ❑New❑Repair N.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> (TYPE OF PUMP) <br /> ❑ OUT-OF•SERVICE WELL ❑ GEOPHYSICAL WELL R ❑ SOIL BORING R <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 8 I"ZA DIA.OF CONDUCTOR CASINO D <br /> ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEUPVnC Z/I n✓C DIA.OF WELL CASINO <br /> ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL Sr. f9 SPECIFICATION <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME J/- <br /> MONITORING / GROUT SEAL PUMPED:*Ye. [IN. CONCRETE,{PEEDESTAL BY DRILLER:[�I Y« ❑Ne S <br /> APPROX.DEPTH 3S LOCKING CHESTER BOX/STOVE PIPE -F u/4 <br /> PROPOSED CONSTRUCTIONIDRILLINO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> 1 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 LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'f CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS Of <br /> CALIFORNIHEMPUCANj�CAU.24 HOURS IN ADVANCE FOR ALL REQUIRED INI�ECTN)NS A ( <br /> ne20SI�r�� C_ E DRAVNNO AT LOWER Data <br /> aPROVI�D. <br /> Sipd X J/Y ppJJ "�/Lr �,/f <br /> PLOT PLAN(Draw to S—W Seal. 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WMAN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> E............... ...E.. ..i _... <br /> ... ...:.. ..:.....:......;.. ..i.... <br /> - - ... . .... .. - - ...... .. <br /> - _ <br /> - .... - 1 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By _ �'^•' V \ Dal. I 6f /Ars.�vl ,o-' <br /> Grout Impaction ev Dae Pump Irnpeetlon By rr /iDate <br /> Dn.tnicllen In.pee Ion BY <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHE / ASN RECEIVED By DATE PERMITMEiVICE REQUEST NUMBER INVOICE <br /> o to I <br /> Put,Health Serv.-Enviro.173(1/97) <br />