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SAN JOAQUIN COUNTY PUBLIC HEALTH S DICES <br /> ENVIRONMENTAL HEALTH DIVISIOkl <br /> 3ST WEBER AVENUE, STOCKTON, CA202 <br /> AUGn L. qn p 1999 (209) 468-3420 <br /> Af UG . NON-REFUNDABLE PEINT EXPIRES 1 YEAR FROM DATE ISSUED AUS 6 o 6Jv <br /> ICetnpl$t$In TApikBtel <br /> APPLICATION IS HERE SY MADE TO THE SAN JOAOUM!COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.If 116 APPLICATION ie MADE IN COMPLIANCE WITH SAN <br /> JOAGUM COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 ANJD,THE <br /> �STANDARDS OF SAN JGAOU1N COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION.JOB AODREemn APNJ (D6 STV Y C..1 CITY PARPARCELBIZEIAPNI ( 420 <br /> OWNER'S NAMECt-� in AOOg$e +p <br /> QS [ INCr 51 m& PHONE <br /> I t <br /> CONTRACTOR --_I �_ _- sCC.0—i.i�-� PLC AbbRE$S .cApC� G �C� ilk. LIC,I PHONE I_579—LZ L1 <br />-. SUN CONTRACTOR ArOeLfttl � � ADDRESS 14,4 of&., -=L,A �. <br /> l.RCI PHONE <br /> TYPE OF WELLMUMP; NEW WELL CJ REPLACEMENT WELL *�MONITORINO WELL s :30 OTHER <br /> MSTAUATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL f J <br /> {TYPE OF PUMP1 <br /> El N.13Re•w, H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br />� O <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL/ ❑ SOIL SOMNO a <br /> DESTRUCTION- ' <br /> INTENDED USE TYPE OF WELL CORtTRUCTION SPECIRCATIONS ■. A <br /> I <br /> 13 INDUSTRIAL ❑OPEN BOTTOM OIA.OF WELL EXCAVATtOk 6' DIA.OF CONDUCTOR CASINO ry(A p <br /> ❑ OOMESTICIPRIVATE ❑GRAVEL PACKMZE TYPE OF CASMOISTEE[fPVC V L DIA.OF WELL CASINO Z., O <br /> ❑ PUBUClMUMMAL ❑DRIVEN DEPTH OF GROUT SEAL_ 3 SPECIFICATION �S.-C., n <br /> y❑ IRCtlOATIONlAO O7HEq GROUT SEAT INSTALLED <br /> y BY �ytwu4L 17t()J-- GROUT BRAND NAME w4Ki�k E <br /> �I'MOwrO1VNO '�Ly C%GROUT REAL PUMPEOT#9 YM 13No CONCRETEPIE STAL SY DRRIEM Q Y• &go S <br /> APPROX.DEPTH Zig J l LOnM CHESTER SOXISTOVE PIPE S <br /> PROPOSED CONSTRUCTIONMMIL JNG METHOD: MUD ROTARY AIR ROTARY <br /> AUGER CABLE OTHER <br /> I HEfiEBY CERTIFY THAT 1 IIAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAOUI N COUNTY ORDINANCES.STATE LAWS.AND RULES AND <br /> REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AOEHT-e SIGNATURE CERTIFIES THE FOLLOWING''1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED.1 81IALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORMA.' CONTRACTOR'S HIRING OR BUN-CONTRACTWO SIGNATURE CERTIFIES <br /> THE FOLLOWING! •I CERTIFY THAT IN THE KFIFORMANCE OF THE WORK FOR WHICH TRRB PEIS.47 18 I$SUEO.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN's COMP91SATtON LAWS OF <br /> CALIFORNIA.' THE APPLICANT MUST CALL 24 NoUtS IN ADVANCE FOR ALL RE4UIREo INSItiicTION$AT N"i"S'D427. COMPLETE DRAWING AT LOWER AREA PROVIDED. - <br /> $IO'+ed X Tloo Data <br /> OT PLAN 01—l•Beal*I Beal* 'to . <br /> I- NAMES OF STREETS OR ROADS NEAREST TO OR BOUNoIM THE PROPERTY. 4, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY.GrVMIO DIMENSIONS AND NORTH DNIECTION. EXPANSION OF SEWAGE DISPOM-SY17EM9. <br /> 3. DIMENSIONED OVfIINF.B AND LOCATION OF ALL EXMTMM AND PROPOSED S. LOCATION OF WELL. MKTs11N Mn•K ne HE HUNOMD FIFTY FT. <br /> STRUCTURES. s n Y <br /> m• o a � I ; <br /> - - <br /> Wo a `a�o � <br /> m o <br /> Nx� CL <br /> 9 <br /> } � <br /> LU <br /> DEPARTMENT USE ONLY <br /> Date t <br /> Gout In*P*allan er Oal• <br /> - R�P In*Peeel•n By <br /> 0—ill.atlen 110"lon BY Dote <br /> Cemmakrr _ <br /> Dote <br /> ACCOUNTING ONLY; AID/ <br /> FAC/ <br /> PE CODES FEE INFO AMOUNT REMITTED CHECXN(CASH RECENTO BY DATE <br /> PEiISOTHEIVICE fiEQUE87 NUVR66t INVOICE <br /> 0 ' Z 1532 <br /> Pub Health Serv.•EnvirG. 173(vm <br /> I <br /> s <br />