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-e•d -1H101 <br /> APPLICATION FOR WELU01IMP PERMIT <br /> '-t/ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388,44(r-#.8RN�IMIU STOCXTON,CA 96201.388 <br /> (209)468.3420 <br /> NON-REFUNDABLE PERMIT EXPIAES 1 YEAR FROU DATE ISSUED <br /> ICemplete M T►IpRsate) <br /> Application is here by made to the San Joaquin County for a permit to construct and/or Install the work delcr(bed. This application is <br /> made in compliance with San Joaquin County Development Title, Chapter 9.1115.3 and the Standards of Son oaquin county Public Health <br /> Services, Envirormenta/t/Health Division. ,/ <br /> Job Address/or APNN /AiXO City DUTY- Parcel Site/APNN 45.620-O9 <br /> Owner's Name Bh& &.4- 5'lZx/C%7'// Address Z zD . ��� "`- _I Phone 0 4W=9f-6-d 296 <br /> Contractor �.�/CL/if/lp Address 3233 f2 � Li'et Ad i(A�9 Phone N9f01o3�- 0 <br /> I <br /> Sub Contractor 5'/�h�i� ���C/fiC �Lf/C' Address l/�//1 Ls��i""���✓Qf'L,4 (yE Lfc:Y �J Phone <br /> TYPE OF WELL/PUMP;, EN WELL I3 REPLACEMENT WELL 11 ITORING WELL tF�a 11 OTHER <br /> 11 DESTRUCTION 11 CUT-OF-SERVICE WELL O GEOPHYSICAL WELL 0 L1 SCIL BORING <br /> (I INSTALLATION (1 WELL SYSTEM REPAIR 11 CROSSCONNECT REPAIR 11 VAPOR ER TRACTION WELL N <br /> 11 New 11 Repair N.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONi/> <br /> p INDUSTRIAL 1) OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDU TOR CASING <br /> I) DOMESTIC/PRIVATE jj1(�ORAVEL PACK/SIZE�11T TYPE OF CASING/STEEL/PVC ZP41e DiA. OF WELL CASING Q <br /> (I PUBLIC/MUNICIPAL v0 DRIVEN DEPTH OF GROUT SEAL < -Fr�T' SPECIFICATION NOrr 40 <br /> 11 IRRIGATION/AG ❑ OTHER GROUT SEAL INSTALLED SYIJKL(1� GROUT BRAND N <br /> MONITORING _ GROUT SEAL PUMPED: 0 Yes ANO CONCRETE PEDESTAL BY ORILLER:Ig Yes 11 No 1\1 <br /> APPROX.DEPiH <br /> Zt� LOCKING CHESTER BOX/STOVE PIPE �t <br /> W <br /> PROPOSED CONSTRUCTIONIORILLIHO METHOD: MUD ROTARY„_AIR ROTARY_AUOER,,-_,CASLE_OTHER_ O <br /> I hereby certify that i have prepared this application and that the work Witt be done in accordance with Son Joaquin County Ordinances, <br /> State Laws, and Rules and Regulations of the San Joaquin County. Now owner or (lepnned agent's signstur4 certifies the following: "I <br /> certify that in the performance of the work for which this permit is Issued, I shall not employ persons subject to WORKMAN'S COMPENSATION <br /> Laws of California." Contractor's hiring or subcontracting signature certifies the following: " I cer ify that in the performance <br /> of the work for which this permit is issued, I shalt employ persons subject to WORKMAN'S COMPENSATION Laws qf California." THE APPLICANT <br /> MUST CALL 24 HOURS IN A"D CE FOR ALL REOUIREP IDOPECTIOIIS AT 4051408.3423. Complete drawing at lower area p ovided, y��33 <br /> Signed X Title SLS E;YI?4 4xaPA.<7- oate*t <br /> PLOT PLAN (Draw to Scale) Seale v I /���o <br /> 1. Names of streets or roads nearest to or bounding the property. 4. Location of house ewage disposal system or <br /> 2. outline of the property, giving dimensions and North direction. proposed expansion of sewage disposal systems. <br /> 3. Dimensioned outlines and location of alt existing and proposed S. Location of wells thin radius of 150 ft. on <br /> structures, including covered areas such as patios, driveways, the property or ad Dining property. <br /> and walks. <br /> N <br /> BONN <br /> TL <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date 12,��� Area <br /> Grout Inspection By Data Pump insp�lectti'oin�By Date <br /> /� <br /> Destruction Inspection By Date Comments: GW�s 0 d <br /> ACCOUNTING ONLY: AIDN I FACN11 1 <br /> O <br /> PE CODES FEE INFO AMOUNT REMITTED CRECKOICASH AECEIV 0 BY PATE PERMITISERVICE REOU113T CUMBER E <br /> Zfool <br />