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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIYISIION,.,T.1 <br /> P.O. Box 3m 304 <br /> ROW 419 <br /> *%I <br /> NON-REFUNDABLE PERMIT EXPIRES I YUkinom-0 SSUEO <br /> (Complots In Tr4ill1lesto) <br /> APPLICATION 19##ERE By MADE TO THE BAN JOAGUIN COUNTY FOR A PERMIT <br /> To �Nl TRUCT AND/On INSTALL THE WOW DESCRIBED.THIS APPLICATION 18 MADE IN comPUANpj,VMIf SAN <br /> 'VAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVIstopo. <br /> JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE S!T=G�� <br /> ­nl <br /> 309 ADORESWOn APN# .- w-1PARCEL alzempw 163-07-03ro <br /> OWNER'S NAME CiNcof Stockton I.-DPW ADORES@ -21f Lf ffiCi <br /> do.Sfocklon-35,zc 09- <br /> ASi - <br /> CONTRACTOrk-c—amp— Dre&ser. M 4? <br /> A4 88 1 00ingle ve, fe.Add <br /> WaIn(Al- t".eje rA -a PHONE <br /> pa <br /> SUB CONTRACTORtc, <br /> N (a <br /> d-�N <br /> _TYPE OF LUPUMP. 11 NEW WELL 0 m"cemm WELL MONITORING 1APEL <br /> NeiA t twfirA INSTALLATION 1-1 WELL SYSTEM REPAIR CROSS-COf*4td LV w 00, <br /> �Wo* NAVWR EXTRACTION WELL 0 <br /> BlAcid.erflA eE1N.13R.P* H.P. DEPtt&bMP SET T,�IFT. IF-7 FIRST WATER LEVEL <br /> (TYPE OF PUMP) Is -97 <br /> 11 ou-r-or,vermcE wat 11 GEOPHYSICAL WE iLL ❑ SOIL BORING <br /> 13 DESTRUCTION- <br /> EMT] <br /> INTENDED USE TYPE OFWELL ON�STRUCTION-�-"E-Ct-FI-C�rTIO—NS A <br /> 13 INDUSTRIAL 0 OPEN BOTTOM DIA.OF WELL EXCAVATION 10-in 4rk — VIA.OF CONDUCTOR CASING floe ee <br /> 1:1 DOMESTIC/PRIVATE 10 GRAVEL PACK/SIZE TYPE OF CASIROMIFIEUr -r OF WELL CASINO 'tl <br /> 11 PUBLIC/MUNICIPAL CI DRIVE" Lontstim t- DEPTH OF GROUT SEAL Vl -1 C . k DIA. ­!j­I <br /> _mwfi-� - BMCIFICATION_53i_bfatQndfEt/(-ei-nent",k <br /> ' <br /> 1-1 IRRIGATION/AG ❑OTHERGROUT SEAL INSTALLED air f!Ir-fAf,*-rTv GROW BRA— NO NAME <br /> 10 MONITORING t414-w-?A I LIO a GROUT SEAL PUMPED-MY. [In. i-tt,loyll't, CONCRETE PEDESTAL <br /> Y a DMILE11:0Y. [IN. t4N <br /> APPROX.Dt"14 tAW--7 60f+. LOCKoNG C"E811n SoXMOVF PopFAj"j Co <br /> _�pjtjjbVj wilockinq ear, <br /> PROPOSED CONOITIUCTIONMAHUNG METHOD: MUD ROTARY AIR ROTARY—AUGER CABLE 01"En <br /> I tIMBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WIT"SAN JOAOUIN COUNTY ORIDINAIfrtfl,STATE LAWS.AND RULES AND <br /> REGULATIONS OF THE SAN JOAOUFN COU"TY, HOME OWNER OR LICENSED AOEN`r,g SIGNATURE CERTIFIES THE FOLLOWING-*1 CERTIFY THAT IN THE PfRrOnMANC1!OF THE WORK FOR ValtCtf <br /> 1140 PERMIT 19 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTINO 810"ATU"E CERTWIEN <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PER OF THE WOW FOR W141ctf THIS PERMIT is ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COPAPP1,16ATION LAWS Of <br /> CALIFORNIA.* THE APPLICANT MUST CO)LL 24 HOURS IN ADVANCE FOR ALL 1111GUIRED IN LTIONS AT f2881488-2122 COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Stoned X_ Wddlk���4 Tht <br /> . I - note <br /> Pt-OT PLAN 0ew.to 80*101 scale •to <br /> 1. NAMES OF STREET@ On ROADS NEAREST TO ZROUNOING THE PROPERTY. 4. LOCATION OF HOUSE SF.WAoE cAspogAL qyqTFpA on pRGrOgj1G <br /> 2. OUTLINE OF TIM PROPERTY,OMM Dfovleolog000ts AND Nopor"DIRECTION. EXPANSION or SEWAGE vigmpAL qySoEpAq, <br /> S. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND Pnoposev <br /> GTRUCTUREB,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. a- LOCATION OF WELLS WITHIN RAVRIB OF ONE HUNDRED rw-,ry FT. <br /> C".r `� " <br /> gW-47A <br /> a <br /> LCI VIA] <br /> r?r a.5::'11 P"V <br /> 'JAN 3 0'. 09' . <br /> A N j C "C'.'. <br /> ' <br /> '4 <br /> PUBLIC <br /> HEAl:Tf <br /> VJRQ.NM:EN7ALHEA1LT1 <br /> 11310i <br /> ........... ............ <br /> ............. .......... <br /> DEPARTMENT Use ONLY <br /> flyDate b f-/ <br /> 7- —7 Amo -Z <br /> aftnot Impaction By vote—Pa"p Inopmolon By Date— <br /> By Date <br /> Commmog! ee^­%:f Adrl u,4,/ !Cl� r W �14 I f0 41�teol all". <br /> 001-ove 0 <br /> C IWMB k de hrm e i ir C k 114 f C a ri he drim 47 do,rfa f, (40402 0 14 J -A <br /> # <br /> LACCOUN11180 ONLY: AID# FACT <br /> PE CODES FEE MFG AMOUNT REMITTED C111 #/CASH RECEIVED BY DATE PERMITISFIRVICE neourat NUMBER <br /> INVOICE <br /> QLL <br /> 0 Q3-5 <br /> Pub.Health Serv.-Enviro.173(3(96) <br />