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Dow <br />( Amilatfon AINIMINIMO By <br />Omit Ine.444144. By <br />NA4Acni 41 <br />Clato 1(711 Pwre Irwowtten By <br />Ow. Dewnsetion Inweallsw By <br />AIDS ACCOUNTING ONLY: FACE <br />DEPARTMENT USE ONLY <br />Cewmantet <br />' te <br />4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />5-415 <br />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 Pt Triplicate) <br />ApottuaioN 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 WITH SAN <br />JOAQUIN COUNTY DEVELOPMENT TrTI.E. CHAPTER 9-1 1 15.3 AND THE STANDARDS OF SAN JOAQUIN couNre PUBUC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR APICI I I (C 5t St. Stockt-cti F:54*-3 CITY CS"-rC‘C kr011 PARCEL SIZE/APN0 <br />OWNER'S NAME C -N oc ADDRESS /42s-u.a. borman St-CC-1-0#1 <br />CONTRACTOR A-T. C. A-sscc....iccte-5 AooftEss 117 Lc AL- rn cci.e5tp <br />RUB CONTRACTOR ‘If 4 LO "Dri <br />PHONE <br />1,40NE I 2cits-ri/zz- <br />Ammo, RO- -Box_ 5-1 Rc .Ast tiCs 72.0/04 PHONE 7o7/31/-2.3( <br />REPLACEMENT WELL <br />0 WELL SYSTEM REPAIR <br />H.P. <br />OM-OF-SERVICE WELL <br />)<MOINTOR/N0 WELL 2- 0 OTHER <br />CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELL <br />DEPTH PUMP SET FT. <br />GEOPHYSICAL WELL <br />TYPE OF WELL/PUMP: NEW WELL <br />o INSTAU.ATTON <br />CI New CI RacwIT <br />(TYPE OF PUMP/ <br />FIRST WATER LEVEL <br />0 SOIL BORING <br />0 DESTRUCTION. <br />INTENDED USE TYPE OF WELL <br />INDUSTRIAL <br /> 0 OPEN BOTTOM <br />DOMESTIC/PRIVATE <br /> CI GRAVEL PACK/SITE <br />PUISUC/MUNICIPAL <br /> 0 DRIVEN <br />IRRIGATION/AG <br /> 0 OTHER <br />14 MONITORING <br />APPROX. DEPTH <br />PROPOSED CONSTRUCTION(DISILLING METHOD: MO ROTARY <br />CONSTRUCTION SPECIFICATIONS <br />i A cif, <br />P VC <br />2.8 <br />r re_rn ..e— <br />anotrr SEAL PUMPED: 0 Y44 0 Ile <br /> <br />LOCKING CHESTER eozsrrovE stet OC <br /> AIR ROTARY AUGER ).< CABLE <br />A <br />DIA. OF CONDUCTOR CASING NA- <br />0 <br />DIA. OF WELL CASINO tilc- 0 <br />SPECIFICATION 3C41 <br />GROUT BRAND NAME Cf...111141-TiOLATOA!.....to <br />CONCRETE PEDESTAL BY DRILLER: 0 Y. 1;:(Ne <br />DIA. OF WELL EXCAVATION <br />TYPE OF CASING/STEELIPVC <br />DEPTH OF GROUT SEAL <br />GROUT SEAL INSTALLED BY <br />OTHER <br />I HEREBY CERTIFY THAT I PIAVE PREPARED THIS APPUCATION 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 UCENSED ACIENT11 SIGNATURE CERTIFIES THE FOLLOWING: 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORE FOR WHICH <br />THIS PERMIT IS ISSUED. 1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKNIAN'S COMPENSATION LAWS OF CAUFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: I CERTIFY THAT IN THE PERFORMANCE OF THE WON( FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF ' <br />CALIFORNIA. THE APPUCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL MOORED INSPECTIONS AT 12001 44114423, COMPLETE DRAWING AT LOWER AREA PRONnoco. <br />TM. 73 Ao...yvr Owe 212_4/49 <br />PLOT PLAN (13/1044 le So•141 B4414 <br />NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. <br />OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECT/0N. <br />DIMENSIONED OUTLINES AND LOCAT/ON Of AU. EXISTING AND PROPOSED <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. <br />PE CODES FEE INFO AMOUNT REMITTED CHECK/MASH RECEIVED BY DATE ?IT/SERVICE REOUEST NUMSER INVOICE <br />fl c9 (20 ICI 1 <br />_ <br />.._ S•001SS2_L J <br />Pub Health Serv. - Emir°. 173 (1/97) <br />Skirled X <br /> ".&.