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APPLICATIfiN ro.q vlul/PRIMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE <br /> ENVIRONMENTAL HEALTH DIVISION Y _ U vv�I111 <br /> P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201 JVD <br /> (209( 466.3420 FEB 0 3 1997 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In TrlpRew) ENVIRONMENTS <br /> APPLICATION IB HERE BY MAGE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOIOR INSTALL THE WORK DESCRIBED.THIS APMICATIOI�( �ByBrM1I`RI�(1'SAN <br /> JOAQUIN COUNTY DEVELO1PcMENT TITLE.CHAPTER 9.11106.3 AND TIIE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTS I 616N/ <br /> JOB AODRESS/OR APNE T' 5�VerTI <br /> (.CSD Y.A/.� CIT! TQ`��H ` ( I' PARCEL SIZE/AM# <br /> OWNER'$NAME <br /> 2 G`r"t��^ 4T ,C CA.-�6,. 'P"r_ ADOREB$ �.na.�,tr�(L�O ( F�^����y�l }J}yS PHONE <br /> 1 <br /> CONTRACTOR_ t UVJ T{L>�L,..,11dWWl T 1 �E ADDREBBJGlWl1T1NI( II\(- LE�J.w>\.•"'-'-LRC! iuC PHONE 10)931-gDly <br /> SUSCONTRACTOR SS W��`u"F \a$1�� a3�- ADDRESS ISV((�fR��SV-P E\' l IWC !T^EQ-� E L{�OS{��PHONE SIS 313-5`JJ� <br /> TYPE OF WELL/PUMP: ❑ NEW WELL ❑ RERACEMENT WELL MONITORING WELL B T)E-"Ig 1�-'ITb ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J <br /> 11N.O RpdR H.P. DEPT"PUMP SET_FT. FIRST WATER LEVEL O <br /> RVPL OF PUMPI <br /> ❑ OUT-0FBERVICE WELL ❑ GEOPHYSICAL WELL/ ❑ SOIL BORING R <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATIONa DIA.OF CONDUCTOR CASINO D <br /> ❑ DOMESTIC"IVATE P GRAVEL PACK/SIZE-3 TYPE OF CASINO/STEEL/PVC -L� MA.OF WELL CASING 1 1 D <br /> ElUB <br /> P UCIMUNICIPAI UT❑DmvFN DEPTH OF GROW SEAL LJ_Jrj SPECIFICATION 5-t S <br /> ❑pttE) <br /> fl <br /> IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED�BRY " ! �� GROUT$MND NAME .(� E <br /> E) MONITORING I GROUT BEAL PIMPED: Vr ❑Ne CONCRETE PEDESTAL BY GRIMM❑Yr QN. S <br /> APPROX.DEPTH 60 LOCKING CHE"En BOX/STOVE.PIK S <br /> PROPOSED CONRT M"ONI LUNG METHOD: MUD ROTARY AIR ROTARY AUGER_CABLE OTHER <br /> 1 HEREBY CERTIFY 114AT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> MOULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CESTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE MWORMANCE OF THE WORK FOR PMICH <br /> TIIm PERMIT IB ISSUED.191HALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENFATTOM"We OF CALIFORNIA.' CONTRACTOR'S HINNO OR BUB CONTRACTING SIGNATVRE CERTIFIES <br /> THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE MW FOR WHICH THIS PERMIT IS ISSUED,I$HALL EMPLOY PERAON8 SUBJECT TO WORKMAN'S COMPENSATION"We OF <br /> CALIFORNIA.- THEAPPLI NT UST CALL Me IN ADVANCE FOR ALL REOURED IINNNSS,FEECCCNOMA AT 110$14419 .22. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> 61,r X i TRI. l�i�CiYEA �S ///G>✓i O.t. //�f^J! <br /> not PAN In'.w Ie B W.I SP.I. 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE BEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE MOPERTY,OIVINO DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYBTFMK <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STNMTUnEe.INCLUDING COVERED AREAS SUCH AS PATIOS,DPVEWAYS.AND WMX$. ON THE PROPERTY OR ADJOINING PHOPERTY. <br /> Gam- <br /> DEPARTMENT USE ONLY <br /> Appllrtlen A...ptM BY D.I. <br /> 01.0 I Prtlen BY D.t. _PMnp IrOr$en BY DKe <br /> OrmNBen IrnrO.n er nn D.I. ll6 <br /> ACCOUNTING ONLY: AHO/ FAC$ <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKlMA91P RECEIVED BY DATE PERMITISEAVICE REQUEST NUMBER INVOICE <br /> 0 Z3- 1-5"7 X-,ef O//S3 / <br /> Pub.Health Sew.-Enviro.173(3/96) <br /> I <br />