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APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON,CA 95202 <br /> (209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICampl/u In TTIpRI1uI <br /> —FILICAT ION I9 HEAE BY MADE TO TM SAN JOAOUN COUNTY FOR A T'FRMfT TO CONSTMXT ANOfOA INSTALL THF WORK OFSCRIREO.TISB ARFLICATION IS MADE W COMPI.IMICEWRIR SAN <br /> JQAOUIRI CO(AYTY DEVELOPMENT TTFLE,CHAPTER 9-1115.3 AND THE BTANOAROS OF BAN JOAOLIIN COUNTY PUBLIC HFALTIf SERVICER,ENVIgNMENTAL HEALTH OIVTMpN. <br /> JOB ADDRESMFI APNf 1 7 4 0 0 B e!.h a rr y Rd CITY Tracy <br /> PMICEL SIZFIAFIM <br /> OWNER'BNAME Rankia Ag Service ADOEB116850 S.Tracy Blvd „Ef <br /> c_RACTDR Freitas Electric, Inc. A �.0.Bx 16 Banta ,x(453962 E,Ow,835-2814 <br /> PUb CONTPIACTOR AD01E88 LICE PHONE/ <br /> TYPEOF WELUPUMP. ❑HEW WELL ❑RET'LACEI.IENT WELL ❑MOWTOWNO WELL I ❑OTHER <br /> y, jL❑.,MSTALLATION ❑WELL SYSTEM REPAIR ❑CROSSCOWECT REPAIR Cl VAfOR EXTRACTION WELL F J <br /> u V N_❑RAPAII H,P, 1– I 12 BE <br /> OEPTN PUMP T U O FT, FIRST WATEf1 LEVEL 24 O . <br /> (TYPE OF PUTAPI <br /> 13 oUT4F-SERVICE WELL Cl GEOPII GS Al-WELL 1 ❑ SOIL BORING g <br /> ❑OEE'TRUCTq N: <br /> INTERbEo ViE TYPE OF WELL Co"IRUCTIOR IFECIFKATIONS A <br /> ❑*MU$TINAL ❑OPEN BOTTOM FAA,of WELL FXCAVATgN DIA.OF CONDUCTOACABING p <br /> ❑DOMESTICWHIVATE ❑ORAVtC PAC1(IMLE TYPE bP CASMOfSTEEL F GIA.OF WELL CASINO p <br /> ❑PVBIICIMUNICIPAL ❑DRIVEN MMN OF GROUT SEAL BF•FCIFICATION q _ <br /> ❑MN.ATIOWAO ❑OTHER OAOLIT SEM.INSTALLED BY GROUT BRAND NAME E <br /> ❑ MOMTOWND OROVT BEAL P)MPED:❑YM ❑Ne CONCRETE PEDESTAL BY DRILLER:❑V. LJ NA 9 1I <br /> AP OR.DIPTN 290 <br /> LOCKrea CNE9TER BOX/81 OVF r+PE S <br /> PROPOIED COMITAUCROMmRILLIRO MIONGb' MUD ROTARY AIR ROTARY AUGER CABLE OTHER (`^ <br /> 1 H0W..BV CERTIFY THAT I IIAVE pFIFPARM TNI#APPMATON ANO THAT THE WOW YALJ_IF DOVE M ACCGROANCF V4TH GM JOAOWH COUNTY OMMA,NCEb.STATE UWS.ANO RVLEI ANO <br /> RIEDLAJLTIONS OF THE$AN JOAOfIN COLRTTY. HOME OWNER OR LICENSED AGENT'S SKUfATURE CERTIFIER THE TOLLOWINO:'1 CERTIFY THAT IN Tm PE70M1ANCE OF INC WORK FOR WMCH <br /> 1I41e PERMIT 191SIlk".I SIIALL NOT EMPLOY PERSONS#UB.rtCT TO WORIONAM'E COEAPEFUAMN LAW9 OF CALIFORNIA--CONTRACTOR'S""NO OR EL1bCONTRACTING SIGNATURE CEFTFIEB <br /> TIE FOLLOMANO: I CERfIFV THAT M THE FERFORVAANCE OF THWIIC <br /> E O/K FOR YHH iH18 PEIB AMfT ISBVED.I IIIAit EMPLOY PER90Nb IJE <br /> UBCT TO WDRKINI,M•■COM/4TIIANON LAW*OE I <br /> CALIFOIMA.- TM Wf MV9T CALL•{I NOLRU W ADVANCE FOR ALL REOC—M M MM/AT 12OWW Atl-IISe.COMRRETf DMMRNO AT LOWER AREA PTIOVTDFD. n <br /> ',,ll,AI <br /> 9--d x �� m TIN. D.I. 2- <br /> ROT PLAN ool n—IP 9Ar.l B'" Ie <br /> 1. NAME@ OF STREFTB OR ROADI WAtEST TO OR SOVNDI`NG THF PROPERTY, A. LOCATION OF HOUSE SEWAGE IXSPOIAL BYSTEM OR Pf10P09Eo <br /> Z. OVTLBIE OF THE PRDPERTY.OMIRM DR.IERIgNB AND NORTH OMIECTXNI. EXPANSION OF IFWAGE DIN08AL SYI1tFAa_ <br /> J. DIMENSIONED OUTLMFI IVO LOCAT"OF ALL EXINT#FO AND FROPOLED 1.LOCATION Of WELL/WRMN RADA/S OF ONE NIRIOIIED FIFTY FT. <br /> BTPIVCTUREI,94CLVMM COVERED APE"SUCH AE PAT".DIaVFWAYS,AND WALKS. ON THE PROPERTY OR ALIJONIfq PROPHITY. / <br /> f24q PAYMENT <br /> JUL 13 1998 <br /> .: ... .; . . ... .. .. ! PUBLIC HEALTH SERVIGES <br /> ENVIRONMENTAL HEALTH DMSIOv <br /> DE►ARTMENT VIE ONLY <br /> ApplbMl.w.Aa.gl.d BY bNA Mr� <br /> Gravy Irwpeellen BY R0.mP IOIPAa IIe..BY ! �L' ONEI��✓��'��! <br /> V rInMIFw 1rwFePllen BY 1DIIA <br /> ACCOUNTING ONLY: AIDE FAC/ <br /> PE Copt/ FEE IWO AMOLIIIT REMITTED C1RCK! AIH AEC911-BY .ATE P6MITIIHWTCE REOUEIT NLIAH6R INVOICE <br />