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4 LICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVI.,.:S <br /> ENVIRONMENTAL HEALTH DIVISION <br /> { N. 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICompbto In Triplkats) <br /> APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE W"It SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9,-1 115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOS ADDnE89/on APNI O �J /[ < � q N CITY_' w� �v�� C� PARCEL SIZE/APN# <br /> OWNER'S NAME <br /> �D h L[ �Cr to t ADDRESS <br /> �/�� / —�p�— 'n /�- <br /> CONTRACTOR /V t [ _A ,� (L L7 1�/1 C ADDRESS ,7/ [ /�J d UCI25q12PHONE ICS —� <br /> SUS CONTRACTOR ADDRESS LICN PHONE <br /> TYPE OF WELLMUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ <br /> S ❑NewRepalr H.P. DEPTH PUMP BET /�FT. FIRST WATER LEVEL l O U <br /> HYPE OF PUMPI <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL/ ❑ SOIL BORING S <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING p <br /> ❑ DOMESTICB4UVA1E ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEEU-PVC OIA.OF WELL CASINO p <br /> '❑ PVRUC/MUNICIPAL 1:1OmVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> C�IRRtGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITORING GROUT SEAL PUMPED: Ely. ❑No CONCRETE PEDESTAL BY DRILLER:❑Yee ❑No S <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S[— <br /> PROPOSED CONSTRUCTIONMAILLINO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> 1 HEriEBY CERTIFY THAT 1 HAVE PREPMED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND \ T <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 WHI <br /> THIS PFnMiT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: "1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S OM SATION LAWS <br /> CALIFORNIA=TRECANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPEECTTIIOONS AT 12051 4693423. COMPLETE DRAWING AT LOWER AREA VIDE <br /> SlOrwrd K Tltle " p De <br /> PLOT PLAN(Drew to Seelel Scele 'to <br /> 1. NAMES Or STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PnOPERTY,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 FIrTY IT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY, <br /> .. :� ... <br /> ...:.. ..:...... ...... ... ...:..............,.... .. ., <br /> ... ..;....i.. <br /> .. ;....... ...... ..... ... .. .. ... <br /> .. i. ;. .. <br /> _ ...... .. .. <br /> :...:............. ...... <br /> l�.✓rte !� r~'`� <br /> 4p iox <br /> .... f h <br /> ; . I � <br /> b..lJ. ..:(d�c w. h.�. <br /> V } t <br /> .....;...... ... . <br /> r <br /> :. ..: ..:...MAY <br /> . ' 119 <br /> : ....; :.....:......:.....:....:.. ..:.... : ...: ..... .. . <br /> !... <br /> AQU <br /> :.......; .... SAN JO <br /> PU3l ICH <br /> EPL7 <br /> WiR: <br /> iVl I Yr <br /> S <br /> N�N I <br /> iJ0 <br /> ENVIRONMENTAL SALT <br /> 1. <br /> DEPARTMENT UDE ONLY <br /> Appllaetlon AeoePted By A � Deb �1 Aru <br /> 0—AImpeatlon By Det. Rwnp Inepeotlan By � DNs <br /> On.tnretlen I-Peotlon BY Dete <br /> Com —tv <br /> ACCOUN i1ND ONLY: AID# FACS <br /> PE CODES FEE INTO AMOUNT REMITTED .EHEC //CASIT RECEIVED By DATE PERMIT/SERVICE REQUEST NUMSER INVOICE <br /> k In <br /> r O 15 5 5 <br /> Pub.Health Serv.-Enviro.173(1/97) <br />