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`,13huii <br />DEPARTMENT USE ONLY <br />Avolleolen AeosoItod By <br />Oreisi Inevectien By <br />Onetruellen Inenecilool By <br />Commen4s, <br />Rums Inelmation SY <br />APPLICATION FOR WELL/PUMP PERM _ <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br />(209) 4684420 <br />ROMREFUNDARE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br />(Complete le Tripkatet <br />APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORE DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />JOAQUIN COUNTY DEVELOPMENT TITLE. CHAPTER 9- 1 1 1 5.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SE ELL ENVIRONMENTAL HEALTH DIVISION. <br />PARCEL SIZE/APIle <br />OWNER'S NAME CO a 1- /217) ADORES* 7. I Id L-GC)(i t*) PHONE .466-24 <br />C RACTOR P I taukA ADORERS 7")A5 'Lill 11./4344.A. 1r, G-12-26C; PHONE / <br />c CijAalT Icri T k-71- 0 c3TO AD.E.812-7q D OjC42 tics 161 752_ PHONE L. <br />FILE COFT <br />JOB ADDRESS/OR APN/ az) LS 1 CRY c_47-o <br />TIN. V L A.26 I E.E.1-,?_ D.. 1217 <br />TYPE OF WELL/PUMP; 0 NEW WELL <br />0 INSTALLATION <br />o Mr", 0 ReAsIr <br />(TYPE OF PUMPI <br />0 DESTRUCTION: <br />REPLACEMENT WELL <br />WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR <br />DEPTH PUMP SET FT. <br />GEOPHYSICAL WEU. / <br />OTHER <br />VAPOR EXTRACTION WELL / <br />FIRST WATER LEVEL <br />SOIL BORING <br />MONITORING WELL S <br />M.P. <br />OUT-OF-SERVICE WELL <br />TYPE OF WELL CONSTRUCTION SPECIFICATIONS ,4 <br />0 OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING Z " <br />4 <br />, /- a <br />F.] GRAVEL PACX/STZE TYPE OF CASING/STEEL/PVC 1(.0 (2-- DIA. OF WELL CASING 2, it a <br />a DRIVEN DEPTH OF GROUT SEAL 3 SPECIFICATION B <br />0 OTHER GROUT SEAL INSTALLED ITY-1-12-I Ikrt. GROUT BRAND NAME E <br />S <br />S <br />INTENDED USE <br />INDUSTRIAL <br />DOMESTIC/PRIVATE <br />PUBLIC/MUNICIPAL <br />IRRIGATION/AG <br />P.-MONITORING <br />APPROX. DEPTH <br />GROUT SEAL PUMPED: OFINo 0 No CONCRETE PEDESTAL BY DRILLER: 0 Y. 0 No <br />LOCKING CHESTER BOX/STOVE PIPE C <br />PROPOSED CONSTRUCTIONMRIUJNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WIU_ BE DONE IN ACCORDANCE WITH ILAN JOAQUIN COUNTY OROINANCEE STATE LAWS, AND RULES AND <br />REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOU.OWING: *I CERTIFY THAT IN THE PERFOISPAANCE OF THE WORK FOR WHICH <br />THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.• CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING; • I cnITI THATl THE pERFORNIANCE OF THE WOW FOR WHICH THIS PERMIT 18 ISSUED, I SHAU_ EMPLOY marrome SUBJECT TO WORKNIAN'S COMPENSATION LAWS OF <br />CAUFORNIA.' APPVICAN URS WI ADVANCE FOR AU. REQUIRED INSPECTIONS AT 12001 4•*41421. COMPLETE DRAWING AT LOWER AREA PRO DED. <br />Mooed X <br />PLOT PLAN 1DrAw to %Wel Boole to <br />I, NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. <br />OUTLINE OF THE PROPERTY. GIVING DIMENSIONS AND NORTH DIRECTION. <br />I:memos:niers OUTLINES AND LOCATION OF ALL EX/STING AND PROPOSED <br />STRUCTURES. INCLUDING COVERED AREAS SUCH AS PATIOS. DRIVEWAYS. AND WALKS. <br />LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />S. LOCATION OF WELLS VIRTHIN RADIUS Of ONE HUNDRED FIFTY FT. <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />ACCOUNTING ONLY: AID/ FACS <br />PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH I SEC SY DATE PERMIT/SERVICE REQUEST NUMBIR INVOICE <br />35°,/ Pr 3/5 t <br />; IX. ..5,62402/z3/ <br />s. <br />Pub ealth Serv. - Enviro. 173 (117)