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A <br />Comments: <br />---731 ApplicstIon Acoeptfx1 By <br />Grout Inspection fly <br />Destruction Inspection Sy Dein <br />reetwooK, musi- be tomptAtzi 3D 15504gin-Q • eatielLt rlailearGillectst- 2.1"Jorlt <br />64-kt P1'10‘^ to fietct 4.)orist. D tlA- e•LA lkiSpeLtiOn CA.v1 b12, 301,2do(riel <br />Dist, Giv119-7, Pump Inspection By <br />DEF Aili'M'air oray <br />Del. 6.23 Ares <br />D•to <br />APPLICATION FOR WELL/PUMP PERMI, <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201-388 <br />(209) 460.3420 <br />FION.REFUNDARLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(C0171084 In Trip'kat.) <br />APPLICATION IS HERE SY MADE TO TFIE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE wort"( DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH <br />SAN JOAOUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1113.3 AND THE STANDARDS or SAN JOAOUIN COUNTY PUBLIC I lEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDFIE.SS/OR APN# .21150 72 desoget 7"9ele ,/ PARCEL SIZE/APN# <br />OWNER'S NAME 3Te/' ?X W' <br />cm( <br />-7-&•J-)1C Re4.46(._ pHON„R3.5-- 6..5? ADDRESS 471 <br />CONTRACTOR GeV g40 .6epe, noonEsagee 6eA.) Lic,,e4477 PRONE 0 f.611 &A/4V <br />ADDRESS <br />CA". LICE PHONE # <br />SUB CONTRACTOR <br />TYPE OF WELUPUMP; El NEW WELL <br />0 INSTALLATION <br />0 New 0 Repair <br />(TYPE OF PUMP) <br />0 DESTRUCTION: <br />INTENDED USE TYPE OF WELL <br />INDUSTRIAL <br /> <br />0 OPEN BOTTOM <br />o DOMESTIC/T'RIVATE <br /> <br />0 GRAVEL PACK/SIZE <br />PUBLIC/MUNICIPAL <br /> <br />0 DRIVEN <br />0,110ATION/A0 <br /> <br />0 OTHER <br />r' MONITORING <br />APPROX. DEPTH sVq0 <br />CONSTRITC-110WiPECIFICATIONS <br />GROUT SEAL INSTALLED BY SeStat, <br />TYPE OF CASINO/STEEL0 <br />DEPTH OF GROUT SEAL -719 Mitc. <br />DIA. OF WELL EXCAVATION 23 1 <br />ft4 <br />4irle <br />LOCKING CHESTE l 71 T.VE PIPE <br />OTHER <br />vAron EXTRACTION WELL <br />FIRST WATER LEVEL <br />DIA. OF WELL CASING ea <br />SPECIFICATION O. oz. <br /> olP• \A\\ <br />GROUT BRAND NAME °P012,41,114 <br />CONCRETE PEDESTAL BY DRILLER: 0Y.. WV; 5 <br />REPLACEMENT WELL <br /> 0 MONITORING WELL: <br />WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR <br />DEPTH PUMP SET FT. <br />OUT-or-SERVICE WELL 0 GEOPHYSICAL WELL <br />GROUT SEAL PUMPED: 0 Yoe <br />El SOIL BORING <br />DIA. OF CONDUCTOR CASING Ash/04 <br />PROPOSED CONSTRUCTION/DRILUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br />CALIFORNIA.' THE AP ANT MUST CAAJ. 24 • MS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT (20E 408-3423. COMPLETE DRAWING AT LOWER AREA ED. <br />Signed X t17t..L11._) <br />THE FOLLOWING: I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPEN ATION LAWS OF <br />THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA. CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br />I HEREBY CERTIFY THAT I HAVE PREPARED TI118 APPLICATION AND THAT THE wons WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES. STATE LAWS, AND RULES AND <br />REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER on LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE VVOPIC FOR WHICH <br />ko''‘,//0 <br />t <br />Till. (CV, Delo g <br />PLOT PLAN (Drow to Sco/o1 Scale <br />I. NAMES or STREETS on twos 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 WAUCEL <br />t o <br />4. 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 />OFF THE PROPERTY on ADJOINING PROPERTY. <br />... ... <br />Nve-4e, CAr-1 <br />... <br />. • • ... <br />... <br />............ <br />ACCOUNTING ONLY: AMA FACE <br />PE CODES FEE INFO AMOUNT REMITTED CHECK/MASH RECEIVED BY DATE <br />PETUVOT/SETIVICE REQUEST NUMBER <br />INVOICE <br />501 <br />Sgoo/zsrelq <br />Pub, Health Sent. - Enviro. 173 (3/96)