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APPLICATION FOR WELL)PUMP PERMIT <br /> �AN JOAOUIN COUNTY PUBLIC HEALTH SERVIO <br /> ENVIRONMENTAL HEALTH DIVISION <br /> RO. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br /> )209) 488-3420 <br /> MON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (CompMta in Tr)pUe{t{) <br /> APPLICATION 19 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 WRH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1116.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOBADDRESS/ORAPNF 34-4 LNNLOLJJ ClENTfG CITY STacitnmo CA PARCEL SIZEIAPN{QQ}-41-7q <br /> �nn ^�I � f 44606 <br /> OWNER'S NAME SCTTI�AI(. V/LU LZtAL111JA nEFfAIDA C�G ADDRESS 1490 POWe"3l�IZ(h Fi&m. rm ILL! A PHONE A(Sle) 65Z-4560 <br /> p oNA(4 T. 9a`.aof uww, Syre G/4Lw ALT NA66w._ <br /> -291NRAs1e1F Lf✓ANA. ly CKE . R( MAI 'ADDREBe 116M- PHBNF/ <br /> 1 \ 9S1AT <br /> SUBCONTRACTOR 5PfCT,L✓,n EXPCONATIOAI}J-NL- ADDRESS Z36 S��WI6VA DA./SrffmLK1 CA LACI 51=9 PIONE 4Ef 8712 <br /> TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ® MONITORING WELL PMLV-IOD ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J <br /> ❑New❑Racal, H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> (TYPE OF PUMP) <br /> ❑ OlR-OF-SERVICE WELL ❑ GEOPHYSICAL WELL/ ❑ 801E BORING B <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION{ A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 10- I N(K DIA.OF CONDUCTOR CASING A/ O <br /> 11DOMESTIC/PRVATE ®GRAVEL PACK/SIZE 6.02-014L TYPE OF CASING/BTEEL/PVC I'- S- STEEL DIA.OF WELLCASINO H-/A/W O <br /> ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTHOFGROVTSEAL SA-F(FT SPECIFICATION CfAl6AJT-Q(AtAYV/TE R <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL NSTALLED BYE ern ' " 7Jc. GROUT BRAND NAME Al 1/JcE--IL F <br /> ❑ MONITORING GROUT SEAL PIMPED: ®Y. [IN. CONCRETE PEDESTAL BY DRLLERAR Y. [IN. 5 <br /> APPROX.DEPTH }U rtFT E1(la.J APO✓NO SPkFAGE LOCKING CHESTER BOX/STOVE PPE /✓0 S <br /> PROPOSED CONSTRUCTIONIDROWNG METHOD: MUD ROTARY AIR ROTARY AUGER HoLLpW- CABLE OTHER <br /> TCM <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'$SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT 18 ISSUED,I SHALL NOT EMKOY PERSONS SUBJECT TO WORKMAN-{COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'$HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'{COMPENSATION LAWS OF <br /> CAUFORNIA.' E A MVST CALL 24 HOURS IN ADVANCE FOR ALL MOUNTED INSPECTION{AT ROES 4pJ42{. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Sl{ned x %� aS q yeAt &— TRI. MAWA611L, <�EerN,1....LxPLOiW FaN. 1NL. Data <br /> " K10- 6&?T RIOT PUN(Draw to SCYeI S M. I-II ul -Nal <br /> 1. NAMES OF STREET$OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE USPOBAL SYSTEMS. <br /> 3. DIMENSIONED OVTUNF.$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 /> AT 30 ✓ Village - <br /> LVMD46CI<8nC6 <br /> VP 1® <br /> ®V <br /> SW-IG MWB� <br /> VP 38 61 <br /> LINCOLN SCHOOL <br /> 6YP< <br /> NMI i <br /> IS <br /> p AMW9 A <br /> Forma Not < �- Mwu p p g <br /> Cleaning Village q <br /> so <br /> �A <br /> O <br /> e <br /> MW-100 Mw104 <br /> �E MW-5 MWII <br /> Gae5lalion V'1Y' MCPVF�V� <br /> MW)s, MW-6 FPCLfL <br /> l <br /> LINCOLN CENTER.STOCKTON,CALIFORNIA <br /> Flpum a'. <br /> 2- PROPOSED SVE,AIR SPARGING,AND <br /> AQUIFER OST MONITORING LOCATIONS <br /> o m im imrtn <br /> Ropy Nit aaM LEVINE•FRICKE it <br /> IL <br /> DEPARTMENT WE ONLY <br /> Application Accel By Y Data 1`�- - (� Ar. <br /> Groh Inapectlon By Date Pump I.pa<tlm By Data <br /> D.t,.tlon Inapeoti.n1B,``Y ^ r Data <br /> Comment.: ::S-. Y�1e -lis l'i1"C7✓ �V• yJ•`L�o <br /> ACCOUNTING ONLY: AID/ FACE' <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK{/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> 220 13 10-7-5-7- r <br />