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f-tue_- I�as5on — Url IT- Li <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> - ENVIRONMENTAL HEALTH DIVISION If'AwNrer <br /> P.O. BOX 388, 446 N. SAN JOAQUIN S,9 STOCKTON, CA 96201-388 (•r ir'I'VIy' 1q! 1 / <br /> ( V.;IT �I Th <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUE Is OC <br /> (Complete in Triplicate) T z 1 <br /> Application is hereby made to the San Joaquin County far a to construct and/or Install the work described. This application Is m dleflp permitr3ence with San <br /> Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br /> Job Address/or APHN 3105 So El Dorado St City Stockton CA 95206 Parcel Size/APHN <br /> Owner's Name California Tank Lines Inc (CTL) Address 3105 So. EI Dorado SL, Stockton CA. 95206 Phone#(209) 4fi6-3554 <br /> Contractor 5jer -Pacific Groundwater C n uita is Inc Address 4911 Windplav Dr. Suite 4 Llc# Phone# (916) 933-1466 <br /> — . . <br /> EI Dorado Hills, CA. 95762 <br /> Sub Contractor West Haz Mal Drilling Corp. Address 3233 Fitzgerald SL LIc4 /, -571r,�S4479 PhoneA.(91e) 638-7276 <br /> Ranco Cordova, CA 95742 <br /> TYPE OF WELUPUMP' II NEW WELL REPLACEMENT WELL [] MONITORING WELL # (11 O)her <br /> f( DESTRUCTION OUT-OF-SERVICE WELL GEOPHYSICAL WELL # ('SOIL BORING <br /> f( INSTALLATION WELL SYSTEM REPAIR [[ CROSS-CONNECT REPAIR (J VAPOR EXTRACTIONTNELL #_ <br /> [[ New Il Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> [j INDUSTRIAL 11 OPEN BOTTOM DIA. OF WELL EXCAVATION-8-inch DIA. OF CONDUCTOR CASING <br /> f� DOMESTIC/PRIVATE [) GRAVEL PACK SIZE TYPE OF CASING/STEEUPVC DIA. OF WELL CASING <br /> f]PUBLIC MUNICIPAL 11 DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> ([ IRRIGATION/AG OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> [[ MONITORING GROUT SEAL PUMPED: fJYes fl No CONCRETE PEDESTAL BY DRILLER: 11 Yes 11 No <br /> APPROX. DEPTH LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY—AIR ROTARY_AUGER_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 licensed agent's signature certifies the following: "1 certify that In the performance of the work forwhich this <br /> 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 certifiy that In the performance of the work 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 (209) 488-3423. Complete drawing at lower area <br /> provided. <br /> Signed �we rue s.o% 9r en ylMEIn4 Cieo`aRla Datel 11 % <br /> PLOT PLAN (Draw to Scale) Scale— P to <br /> 1 . Names of streets or roads nearest to or bounding the property. 4. Location of house sewage disposal system or <br /> 2. Outline of the property, giving dimensions and North direction. proposed expansion of sewage disposal systems. <br /> 3. Dimensioned outlines and locations of all existing and proposed 5. Location of wells within radius of 150 ft. on <br /> structures, Including covered areas such as patios, driveways, the property or adjoining property. <br /> and walks. <br /> Re <br /> i <br /> I <br /> l' (f DEPARTMENT USE ONLY <br /> Application Accepted By Dale 7 Area <br /> Grout Inspection By Date Pump Inspection By Date <br /> Destruction Inspection By Date Comments: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED /CASH RECEIVED BY DATE I PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> i <br />