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I T <br /> APPLICATION FOR WELLIPUMP PERIV <br /> C>, SAN JOAOUIN COUNTY PUBLIC HEALTH SEES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O. BOX 3881904 EAST WEBER AVENUE, STOCKTON, CA 9520i-388 <br /> (209) 466.3420 <br /> NOK-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> x <br /> (C9mp19h In Triplicate) � <br /> APPLICATION IS HERE BY MADE TO 7}1E 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 9-111 S.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSIORAPNI Schaeffer Industries , Shaw..Rd . CRY. Stockton, Ca . PARCELSIZEIAPNR 143-270-04� <br /> C 1 !' <br /> r I <br /> OWNER'S NAME aea Attached List :"ADDRESS PHONE e ' <br /> CONTRACTOR none ADDRESS LIC! - PHONE N <br /> SUBCONTRACTOR S- ectrum Exc loration , Inc . ADDRES82365 Wigwam Dr . I,c, 512268 p..,,,465-- 8712 <br /> ­L09,1=110 CAR <br /> TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONTIORING WELLf ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑VAPOR EXTRACTION WELL U J <br /> ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL d <br /> (TYPE OF PUMP) <br /> ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELLR E3SOIL BORING B <br /> �y21 } <br /> 1XSTRUCTION: Pressure Grout ( 3 ) Wells 2"PVC with Bentonite Grout (Quick Grout-) � <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION It DIA,OF CONDUCTOR CASING IN/A O ! <br /> ❑ DOMESTIC/PRIVATE ❑GRAVEL PACKISIZE TYPE OF CASINGfSTEEIJPVC PVC DIA,OF WELL CASING 21, PVC 0 { <br /> ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION �1 R 1 <br /> 11IRRGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY_Spectrum GROUT BRANO NAME Q u i c l� Grout , <br /> ❑ MONITORING GROUT SEAL PUMPED:n Yee ❑No CONCRETE PEDESTAL BY DWLLER:Ely. ❑NO, S <br /> APRIOX.DEPTH ( 3 ) Wells to 70-75 Feet LOCKING CHESTER BOXISTOVE PIPE S i <br /> PROPOSED CONSTRUCTIONfMILUNG 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 BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: '1 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 SU"ONTR ACTING 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 WORIOMAN'9 COMPENSATION LAWS OF <br /> CAIJF0RNLA,L.THE APPLICANT MUTT C 4 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12091400-S423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> SlpnedX Title " Adra. Assistant Date 1Y"-1 96 <br /> PLOT PLAN{Drew to Seale)9"Id: <br /> 1• NAMES OF STREETS OR ROAD EAREST 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 SEWAQE 7DISAOSAL SYSTEM@. <br /> 2. DIMENSIONED OUTLINE@ AND LOCATION OF ALL EXISTING AND PROPOSED- <br /> .-�N -Fr �- <br /> ........ .. .. ..... .. __ .. - .. .. .. .. .. .....e.......i.... .. .. .. .. _ <br /> ... ......:. : ...:...... ° ... <br /> :... ... ... .. °.....1.-.....i........... <br /> —DEPARTMENT UOE ONLYY—�^..'��� <br /> Appli"tIon Aeeevled BY w Dae �`•-� A+ee <br /> Grout Inspection By Date Pump Inspection By Date <br /> DeHructlon Impeetlon By Date <br /> Comments: <br /> ACCOUNTINO ONLY: AID/ FAC <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKIICASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> 2-50-1- WD <br />