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0 APPLICATION FOR WELL)PUMP PERMIT 96 <br /> AN JOAQUIN COUNTY PUBLIC HEALTH SERVI <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201388 <br /> (209) 468.3420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICompleto in TTipl-Kab) <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 JOAQ N COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> 2�0 f fOkt- A2TH-�L� �DaA V` i 1� e�1 <br /> JOB ADDRESS/OR AM, CITY PARCEL SIZE/APN* <br /> ��P21 rJ7 1"ooDS fsuX 3 F� �c3o <br /> OWNER'S NAME ADDRESS AIL/�� !1 :+ !7L 1 7— �'/UD PHONE 0 Z <br /> CONTRACTOR J �I�LM ADDRESS2-02rjT,. M]L� S�I�'LI�L'M�-(�Q PHONE N.�1U�� <br /> SUB CONTRACTOR ADDRESS { / LIC* PHONE N <br /> Mw- <br /> TYPE OFWELL/PUNEW MP: WELL ❑ REPLACEMENT WELL MONITORING WELL* MW-(O ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL* <br /> ❑New❑Repair H.P. DEPTH PUMP SET—FT. FIRST WATER LEVEL 0 <br /> (TYPE OF PUMP) <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL♦ ❑ SOIL BORING B <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONBTRUDTHIN SPECIFICATIONS A <br /> El INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION �l '' DIA.OF CONDUCTOR CASING 0 <br /> [IN <br /> DOMESTIC/P ATE GRAVEL PACK/SIZE �'/I V TYPE OF CASINGISTEEUPVC Z" S--14 YO PL/G.DIA.OF WELL CASING Z r� 0 <br /> ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL ✓ ,;� C t- SPECIFICATION R <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED By -.k y./' GROUT BRAND NAME E <br /> MONITORING /-�L-. GROUT SEAL PUMPED:O� L/-JI_No ,.��cOyCRETE PEDESTAL BY DRILLER:❑Vw [IN. 5 <br /> tom( piP. I Al s�c�D TL <br /> APPROX.DI LOCKING CHESTER BOT(-/jl/STOVE PE bf�v 5 <br /> PROPOSED CONSTRUCTION/DRILUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE_ OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW 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 <br /> THIS 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 ICI/-EERrJ/�TIIy]FY TT/H/AATT ttN TH HFORMANCE OF THE WOR(FOR WHICH <br /> THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATIIONN' LAWS OF <br /> CALIFORNIA.' wY�///i.//A.M C HOURS IN A71 M Er-)L`"IT INSPECTIONS A/P S. COMPLETE DRAWING AT LOWER MEA PROVIDED. <br /> slanad x ✓� T Data — <br /> PLOT PLAN(Draw to Sulsl Sulo '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 WITHIN RADIUS OF ONE HUNDRED FIFTY FT, <br /> STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> OFF- SITS �c,o- nt�rJS <br /> prJ <br /> kAA-c' A-T-1+u rL DP-1 JE <br /> IM+°rP> ... <br /> J. Ij <br /> Application Acceptetl <br /> DEPARTMENT USE ONLY Ij /r <br /> �d-,C� Date I � � AresO�Gam✓ <br /> B} �- <br /> Grout Inspection BY Data Pump Impaction BY Data <br /> Data <br /> Destruction Impectlan BV r <br /> Comment.: �e 1� einr� c -411F �� Ivy Clime,^of 1 ray �y <br /> ACCOUNTING ONLY: <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK*/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> boa L 'f `t o <br />