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-- <br /> APPLICATION FOR WELLIPUNIP PERMIT ---'--- <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 398, 445 N.SAN JOAOUIN ST.,STOCKTON,CA 9620/389 <br /> (209)4093420 <br /> NONREFUNDABLE PERMIT EXPIRES I YEAR FROM RATE ISSUED <br /> (Camplate Y Trlplkebl <br /> Application Is here by made to the San Joaquin County for a permit to construct and/or Install the Nork described. This appifeatim Is <br /> Rede in compliance with Sen Joaquin Canty Development"Ti�le, Chapter 9-1115. and the Standards of San Joaquin County Public Health <br /> Services, Environmental Health Division. <br /> �.aS?C)CDchn� <br /> Job Address/or APNEbDfLV� — 1[GLC D City Parcel Sfee/APNRx�0rO-Ooh <br /> owner's Meme OSA AMly GrP-r Address�l�o0 ^Cilyl idA lYn�J,. fill Pna,e N <br /> Contractor Pn.-(+A It 1 me oet-; Address�I.�^1 o)II ret9�.. 91,44 7 Lich --- Phone 11%-3EV � <br /> Sub Contractor WalIL : IIl1V Address 1/�L(d e0.. LicN,�b �-C'S�' Phone Nq�(/-�s-aT�a <br /> lT <br /> TYPE OF WELL/PMP: D NEN WELL H REPLACEMENT WELL D MONITORING WELL E D OTHER <br /> DESTRUCTION D OUT-OF-SERVICE WELL E1 GEOPHYSICAL WELLS D SOIL OMIRG <br /> E1 INSTALLATION D WELL SYSTEM REPAIR D CROSSCONNECT REPAIR D VAPOR EXTRACTION WELL N_ <br /> D New D Repair N.P. DEPTH PMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> /i <br /> x'INDUSTRIAL D OPEN BOTTOM DIA. OF WELL EXCAVATION lftollrp DIA. OF CONDUCTOR CASING_ <br /> D DOMESTIC/PRIVATE (I GRAVEL PACK/SIZES TYPE OF EASING/STEEL/PVC'S.]..ee.l DIA. OF WELL CASING <br /> PUBLIC/MUNICIPAL D DRIVEN, C { DEPTH WF GROUT SEAL d4r1r-sn tYlt SPECIFICATION- <br /> (1 IRRIUTIM)ADI U OTHER,,11 GROUT,SEAL INSTALLED BY GROUT BRAND NAME <br /> [I MONITORING / Y / MMT SPAL FUNDED: D Yes I) No CONCRETE PEDESTAL BY MILLER: (1 Yee D No <br /> APPROX.DEPTH (_ �� AA "I.00KIN,CHERTER BOKntOVE PIPE - <br /> IMPOSED <br /> -C{ONNSTRUCTIONIORILLINO_DIEGO p'i MIOl ROTARY nAIR ROTARY_AMER_CABLE_OTHER <br /> 1 L, <br /> Itis' �py- b y Prepared <br /> this piI) anion that <br /> the <br /> won Cil be <br /> don n ctleJn Le with <br /> 1 hereby certify th 1 h e retired this e S n Joaquin <br /> and that the work x 1 be tore In ac r s signature with San Joaquin C ty Ordinances, <br /> State y the end hep end Re9ulef to of the San Joaquin Cermit Name aver or Ilc of ed loy P e ubjcertifies the following:SAT ON <br /> certify that in the-- Contractor's <br /> of the wank for which this perm([ is issued, 1 she Ll he following: <br /> Persons subject to WORKMAN'S COMPENSATION <br /> Laws of California.-- his permit ; hiring or sub-contraeting mon,subject <br /> t to WORK the following: N 1 certify o Ca that 1n she HEAPPmence <br /> o/the work for Milch this permit is issued, 1 0hLL1 slmpley dNrsons eWject to YORXIUN'S COMPENSATION Lawn of California." THEAPPLICANT <br /> MUST CALL 24 HOURS IN ADYANCE <br /> FOFOR�ALL REQUMED.INSPECTION$ATAIII 4503423.,Complete drawing at tower area provided. <br /> signed X� Title f/d1 _�1o'�1s7 1 Gete� � <br /> PLOT PLM (bras, to Scale') &..is_" to - <br /> 1. Names of streets or roads nearesC to or bourdf ng:.the-property. 4. Location of house sewage dfipossl system or <br /> 2. Gunfire of the property,-Diving dlmensi9me.and North;diractl0p. proposed expaMlon of sewage disposal system. <br /> 3. Dimensioned outlines and`loeatfon of st'liexistfng and,pretoded. 5. LocetiwbN•webld within radius rof 150 ft. on <br /> structures, Including covered areas suchPas patios, driveways, the property or adjoining property. <br /> and walks. <br /> 1" <br /> DEPARTMENT USE ONLY 2/ <br /> APpliestiM Accepted By ��� Date ✓V I Arms. <br /> Grout Inspection By - ens Pump Inspection By Date_ <br /> Destruction Inspection By �01Date I Comments: �--/1r� <br /> ACCOUNTING-ONLY: AID# FACE L.'—�O <br /> PE CODES FEE INFO AMOUNTREMITTEDCHECKEICASH JIECDVEO BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> d 3sssl m 3aw 43o v <br /> - I <br />