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CONTRACTOR 1,.."/(aL ) 4/*1.-/ei <br />SUB CONTRACTOR 74* C-.71;1v.driV).11_ <br /> <br />AIR ROTARY AUGER CABLE OTHER (./7/4 <br />LOCKING CHESTER BOX/STOVE PIPE <br />Grout Inspection By q-P Date /V.! Pump Inspection By <br />• <br />III CI IT-1 Area 413 <br />Date <br />60 / /131)i <br />L. O f Application Accepted By <br /> it4 <br />DEPARTMENT USE ONLY <br />Date <br />APPLICATION FOR WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201-388 <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 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR APN# /*X 16—st- 4,4.1 CI1V 3A PARCEL SIZE/APN# O'' <br />OWNER'S NAME 1-0./.4%L cil ADDRESS (X/ z3ce, 4.3.V PHONE (2c) <br />ADDRESS / 4/5"j k Et-,5 UC# PHONE 6/0 .336C) <br /> <br />ADDRESS 2 /?t:.` ek , fle 04 id, uc# PHONE VT) VIC -&:)( <br />/7 •T'&' <br />TYPE OF WELL/PUMP: 0 NEW WELL 0 REPLACEMENT WELL 0 MONITORING WELL # 0 OTHER <br />0 INSTALLATION 0 WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELL # J <br /> 0 New El Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL o <br />(TYPE OF PUMP) <br />0 OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL* SOIL BORING q 6,671 111144" arli7C 4-). B <br />El DESTRUCTION: i42--4A0/ LL Jr iii Ce41,t,e,n. t -- h t- fAric.,t 1 rk ,...., <br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br />INDUSTRIAL 0 OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING D <br />DOMESTIC/PRIVATE 0 GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA. OF WELL CASING D <br />PUBLIC/MUNICIPAL 0 DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ---C, <br />1:1 IRRIGATION/AG 0 OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ..:. <br />MONITORING GROUT SEAL PUMPED: El Yee 0 No CONCRETE PEDESTAL BY DRILLER: 0 Yea 0 No S --...) <br />APPROX. DEPTH <br />PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND (••4 <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 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 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CALIFORNIA " THE APPUCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12091468-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />k Title JTAi• ri( <br />PLOT PLAN (Draw to Sc.).) Scale " to <br />NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. <br />OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. <br />DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. <br />Signed X Date ieriZ <br />LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />Destruction Inspection By <br /> <br />Data <br /> <br />..44,1.51p-4...64.0"......1 <br /> <br />Comments: r <br /> <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK* ASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />F' i Po I Y I Lleif-- it ( c 1 14_ 0r , ,--,-. - <br />3i 45', 7 <br />----.'