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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 />(Complete In Triplicate) <br />APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1 115.3 AND THEE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESSOR APN/ L VO� V�'��%- S CITY s �(' 1( " —`� <br />^ PARCEL SIZE/APNI ` 7 <br />OWNER'S NAME IIa��J - 1�`1 �Z•�TLY W��v� �— ADDRESS L 1:... + a�` K' l� _ PHONE R'Z>.Sl ' 1 ��' ZJ I <br />CONTRACTOR RAf. (A—k(J- —J kP"- - AODRESB L�1� � \�a�1N� � LICIT yPfIONE/ <br />SVS CONTRACTOR V LyS , (LX\. ADORES{ � `"X 51,i 0ca,V UC/Tu` "4019F1-�� <br />TYPE OF WELL/PUMP: .PNEW WELL ❑ REPLACEMENT WELL *MONITORING WELL I ❑ OTHER <br />❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROS8-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I ,/ <br />❑ New ❑ R.P.II H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br />(TYPE OF PUMPi <br />❑ OUT -0F -SERVICE WELL ❑ GEOPHYSICAL WELL* ❑ SOIL BORING <br />❑ DESTRUCTION <br />INTENDED USE <br />❑ INDUSTRIAL <br />TYPE OF WELL <br />C1 OPEN BOTTOM <br />CONSTRUCTION SPECIFICATIONS <br />O <br />DIA. OF WELL EXCAVATION V <br />GIA. OF CONDUCTOR CASINO NF1 <br />❑ DOMESTIC/PRIVATE <br />❑ PUBLIC /MUNICIPAL <br />❑ GRAVEL PACK/SIZE <br />TYPE OF CASINO/STEEL/PVC V G <br />DEPTH OF GROUT SEAL <br />DIA. OF WELL CASING <br />`� Z •� `, <br />SPECIFICATION Y'V`��l'.N }4. <br />IRRIGATION/AG <br />KK❑y�OLtlVEN <br />"iYOTHER <br />�1 <br />GROUT SEAL INSTALLED BY �y�-1M1't y, {�+V <br />GROUT BRAND NAME <br />�❑l <br />1St MONITORING <br />APPROX. DEPTH <br />T "� <br />GROUT SEAL PUMPED: J� Vee ❑ No <br />LOCKING CHESTER BOX/BTOVE RPE <br />CONCRETE PEDESTAL BY DRILLER: ❑ Yee o <br />PROPOSED CONSTRUCTION11MLUNG METHOD: MUD ROTARY <br />AIR ROTARY AUGER CABLE OTHER <br />1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN 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: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR( FOR WHICH <br />THIS PERMIT 18 ISSUED, 1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'l COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR AVB -CONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: ' 1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR( FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'{ COMPENSATION LAWS OF <br />CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INe►ECT/ON8 AT 1208) 400-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />'^/- �"IT- i /�— <br />SIa„ee x �11AJA 'r l ` 7 1.�--:s I LJ Title %(ii.41-lfA� / / / �LDHe <br />PLOT KAN "— to S-1al %.I. ' to <br />1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUN04NO THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />2. OUTLINE OF THE PROPERTY, OIV*M DIMENSFONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />3. DIMENSIONED OU7LINF8 AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WFTMN RADIUS OF ONE HUNDRED FIFTY FT. <br />STRVCTVREB, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINING PROPFRTY. <br />Appneetl— A ... pled By LC -7L4 1 �'�IN1lG h <br />Grout Impeetk- By ,L \. 1�/�,i�(� C" <br />D—t—llen f -V-0— By <br />C. --w <br />w 0 <br />&'x <br />aai <br />Qoa w <br />0 <br />•s <br />Z- <br />W a <br />w � a U z <br />t <br />z n oQ O <br />Q O U- <br />Q m O J o -J <br />O Q <br />d Q O L' U <br />a z a a <br />n J O0 a O <br />w O y J <br />tow U W y <br />w O In U <br />Eiy t— W O <br />O Ln O ~ <br />0 N <br />i7 <br />i� <br />W <br />W <br />L� <br />Dele--u_ A— <br />Pump Impeetien By -( Mn Det.(L L <br />ACCOUNTING ONLY: <br />z <br />w <br />PE CODEe <br />FEE INFO AMOUNT REMITTED CHECK//CASH <br />RECEIVED Sy DA E PERMIT/SERVICE REQUEST NUMBER <br />O <br />3 <br />oo{ 00 ✓ <br />< <br />Z <br />O <br />O <br />Z <br />�J <br />U0 <br />O <br />O <br />J <br />W <br />J <br />3 <br />O <br />o <br />E <br />z <br />o <br />o <br />`^ <br />m <br />o <br />� <br />d <br />J <br />J <br />O <br />Z <br />O <br />cr <br />$ <br />z <br />Z <br />W • <br />W <br />0 <br />0 <br />$ <br />a <br />8 <br />J <br />Dele--u_ A— <br />Pump Impeetien By -( Mn Det.(L L <br />ACCOUNTING ONLY: <br />AID/ FACS <br />\J /E' /�,6�` ✓ %r' <br />C/ <br />PE CODEe <br />FEE INFO AMOUNT REMITTED CHECK//CASH <br />RECEIVED Sy DA E PERMIT/SERVICE REQUEST NUMBER <br />INVOICE <br />3S� <br />oo{ 00 ✓ <br />Pub Health Serv. - Enviro. 173 (1/97) <br />O <br />