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APPLICATION FOR WELL/PUMP PERMIIT O � (�S <br /> P2, <br /> SAN&OUIN C&UNTY'PUBLIC HEALTH SE ES <br /> 'wENVIRONMENTAL HEALTH DIVISION 2 OI2 <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> ( 468.3420 ORIGINAL <br /> NUN-REFUNDABLE PERMITRMIT EXPIRES 1 YEAR FROM GATE ISSUED <br /> ICImpIIu In TriplkEb) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR-A FERMIT TO CONSTRUCT ANDion INSTALL THE WOR(DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITII SAN <br /> JOAQUIN COUNTY DEVELOPMENT TRIE�CHAPTER 9-1116.7 AND THE STANDARDS OF BAN JOAOUIN COUNTY PUBLI/C HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. B. <br /> JOB ADDRESSOR ARNty37�a 41 ,00l'j I PN7Ler CITY SY-OL'17'tM - S,OY.r u � '1 <br /> PARCEL 81ZElAPI1I <br /> Ssd'{l!m FJr leatii D,. mc(w,a/�s CSD Ds) /900 Trowell C4 & F/9 <br /> ONnJER'e NAME C/O T>,-9 IdT a cjT �I�p�✓,ppRE88 Eras rc�r,i//F. C./�? 9Y608 -/8w17 PHONE t.s/D-/rsSe7-y Snn <br /> CONTRACTOR - ADDRESS L/01 PHONE I <br /> ((11 // .2365 (.fJi9uMm 'Dn <br /> BVB CONTRACTOR/-JPCLT/"Gl r.-. ADDRESS .$ roe-F I4 n CA 9Jwo.5- LICI PHONE <br /> TYKE OF WELL TUMP: ® NEW WELL ❑ REPLACEMENT WELL ® MONITORING WELL t ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CRDBSCONNECT/REPAIR 11 VAPOR EXTRACTION WELL t <br /> ❑N.13 F. .lr N.P. DEPTH PUMP SET A//N FT. FIRST WATER LEVEL O <br /> (TYPE OF RIMPI TTT - <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL t ❑ BOIL BORING g <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS •A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA,OF WELL EXCAVATION q DIA.OF CONDUCTOR CASINO N/A D <br /> 11OOMESTRCTRIVATE IN GRAVEL PACK/SIZE # /O TYPEOFCASINOISTEELP C S('/A NO YYC DIA.OF WELL CASINO „7V D <br /> ❑ PISUCANUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL BPECINCATKIN R <br /> 11MOATION(AG ❑OTHER GROUT SEAL INSTALLED BY J)ry Ile r GROUT BRAND NAME&,10,1 Op e1 )71 B NL,L E <br /> ® MONITORING n GROUTSEALFUMPEO: ®Yr [IN. ET <br /> N. CONCREPEDESTALBYDRILLER:MYr ❑N. S <br /> APPROX.DEPTH 9DY LOCKING CHESTER BOX/STOVE RPE ,des s <br /> PROPOSED CONSTRUCTIONANOLUNO 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 GAN JOAOUIN COUNTY. ROME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT LATHE PERFORMANCE OF THE WOW FOR WHICH <br /> THIS PERMIT IR ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS Of CALIFORNIA.' CONTRACTOR'S HIRING OR BUB-CONTRACTING SIONATV@E CERTIFIES <br /> THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSAT.-T LAWS OF <br /> CAUFO IA' THE APPIICMT MUST C 24 MUM IN ADVANCE FO ALL REQUIREDa0INS/IPECTIONS AT CHNN SII-SIES. COMPLETE DMIMM AT LOWER AREA PEIOVIO D. ((LL\L]1LT <br /> 81, % TIO.di 7e. �YYI�P MQ/JTQ q P. Y'- ONa \ `L <br /> PLOT PUN Vr. t.S..I.1 S.N. -I. <br /> 1. NAMES OF STREETS OR ROAM NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PbPOSED <br /> i. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> G. DIMENSK)NED OUTLINES AND LOCATION OF ALL EXISTING ANO PROPOSED S. LOCATMN OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTUnES.INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PMPERN OR ADJOINING PROPERTY. <br /> m '9p anew. <br /> DEPARTMENT USE ONLY 7-51-14? <br /> ^f a/�(yam" /,-� (Y�� <br /> Appkatlpn A. wtp BY `.!: � D.I. /, - ✓1 C U Mu W 4 <br /> Gr.u1 Irap..Ibn By O.I. Pmp In.proSan By D.t. <br /> be.tnalbn Imn..Ibn BY D.Ia <br /> C.m .: 2 0/ -Z cos /Zocy - oG <br /> ACCOUNTING ONLY: AIDS FACt <br /> PE CODES FEEINFO AMOUNTRWITTED CHECKIICAGH RECEIVED SY DATE PEAMITISERVICE REQUEST NUMBER INVOICE <br /> 0 I '15%9D � � O <br /> _ Pub.Health Serv.-Errviro.173(1/97) ����� <br />