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�}eue. Sasson <br /> oAN JOAQUIN COUNTY PUBLIC HEALTH SERVlr _ - - <br /> ENVIRONMENTAL HEALTH DIVISION if��' do <br /> P.O. BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96207388 , �N - '- r q <br /> (209) 46420 ' 1:- 1 ' VY <br /> 83TAL <br /> �'��4 �1� <br /> F� <br /> ' r <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUE Q Ur *.mj <br /> (Complete in Triplicate) I <br /> Application is hereby made to the San Joaquin County for a permit to construct and/or install the work described. This application is made in'E642nce 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 APH# 3105 So. EI Dorado St. City Stockton, CA. 95206 Parcel Size/APH# <br /> Owner's Name California Tank Lines. Inc. (CTL) Address 3105 So. EI Dorado St., Stockton, CA. 95206 Phone#(209) 466-3554 <br /> Contractor Sierra-Pacific Groundwater Consultant's Inc Address 4911 Windplay Dr. Suite 4 Lic# Phone# (916) 933-1468 <br /> EI Dorado Hills, CA. 95762 <br /> Sub Contractor West Haz Mat Drilling Corp. Address 3233 Fitzgerald St. Lic# (C-57)554979 Phone#4,9161 R3R-7978 <br /> Ranco Cordova, CA 95742 <br /> TYPE OF WELL/PUMP: [] NEW WELL [] REPLACEMENT WELL 0 MONITORING WELL #. [] O her ( � � <br /> [] DESTRUCTION flOUT-OF-SERVICEWELL 0 GEOPHYSICAL WELL # [MOIL BORING U <br /> [] INSTALLATION 0 WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR [] VAPOR EXTRACTION WELL #_ <br /> [] New [] Repair H . P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> [] INDUSTRIAL 0 OPEN BOTTOM DIA. OF WELL EXCAVATION_8-inch DIA. OF CONDUCTOR CASING <br /> O DOMESTIC/PRIVATE 0 GRAVEL PACK SIZE TYPE OF CASING/STEEL/PVC DIA. OF WELL CASING <br /> OPUBLIC MUNICIPAL [] DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> [] IRRIGATION/AG [] OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> [] MONITORING GROUT SEAL PUMPED: [] Yes [] No CONCRETE PEDESTAL BY DRILLER: [] Yes [] 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: "I certify that in the performance of the work for which 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 \� I J �— Title SLP <br /> LP 10 � L.nai r*e !J (�et) ej -} DateIOIT ql�> <br /> PLOT PLAN (Draw to Scale) Scale " 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 /> o,r•, Re v <br /> _TF <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date ?// G� 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 HE /CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> S cq9i .� 7 Z O�S'� z3 M 7 a <br />