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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 /> ICompI414 In TrlpRe4tel <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.71118 APPLICATION 18 MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE. <br /> CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESS/on <br /> APN/ l.- LU�� ,�����u CITY mptt-tv k , Y PARCEL SIZE/APNf 1 <br /> OWNER'S NAME '-�c?<<L4�'Q �,p`��/� .,"QN ADDRESS Z�/�. -��•Cy'�--5p\ L+�'(� 1 i'FIONE f ,�Y <br /> CONTRACTOR CGU 1-�J GLT4aT RE <br /> 4- / ,IA�� ADO88Pn. rte-'J( S 1.IC7 V151h UCf,IZ-(FI Uel PHONE/1� �c'G7 <br /> IT <br /> C.cnl�.t.1 1.1�' tvl 213'9 ,�I��/ q� <br /> ADDRE88 Y�'1 x. 10-f� Ir"�U UCf �Y"^"�`���PVIONEf 20f'j L7(,f'1 e�Z�3 <br /> TYPE OF WELL)PUMP; ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL f ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROBB-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL f ,! <br /> El ClReo.Ir H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> R YF'E OF PVMPI <br /> El OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL 1 SOIL BORING ^T- <br /> ❑DESTRUCTION: •� x <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL Cl OPEN BOTTOM DIA.OF WELL EXCAVATION ,�/I DIA.OF CONDUCTOR CASINO /�''�' 0 <br /> ❑ DOME ST IC/PRIVATE Cl GRAVEL PACK/SIZE TYPE OF CASINO/STEEUPVC N 4. DIA.OF WELL CASING <br /> AI /{-' O <br /> ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL !.f-�� ��?��� SPECIFICATION R <br /> ❑ IRRIGATKIN/AG ❑OTHER GROUT SEAL INSTALLED BY l7�Q,/�( GROUT BRAND NAME f ULU-I-AAt,rl E <br /> ❑ MONITORING ! / GROUT SEAL PUMPED: ❑Ye. 0NeCONCRETE PEDESTAL BY DRILLER:❑Y.. ®No S <br /> APPROX.DEPTH X �-X LOCKING CHESTER BOX/STOVE PIPE A. S <br /> PROPOSED CONSTTIUCTION[MLLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HMBY CERTIFY THAT 1 HAVE PREPARED THIS APPUCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:•I 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 RUB-CO MRAC TING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' THE ANT MUST CALL 24 HOURS IN ADVANCE R ALL REOMFO INSPECTIONS AT 12091448-3-423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Sigrood x /- ntl. L d t S c! /I—,- I / D.c.� -yov <br /> t <br /> PLOT PLAN ID—to Bore)So.I. to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF ROUSE SEWAGE D18P08AL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALY'S. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> ... i i <br />