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RI OTHER S f Ploviy W4111 <br />51 VAPOR EXTRACTION WE).L <br />FIRST WATER LEVEL I S <br />0 SOIL BORING <br />INTENDED USE <br />INDUSTRIAL <br />DOMESTIC/PRIVATE <br />PUBLIC/MUNICIPAL <br />IRRIGATION/AG <br />TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br />0 OPEN BOTTOM (HA. OF WELL EXCAVATION <br />rig GRAVEL PACK/SIZE 3 TYPE OF CASING/STEEUPVC <br />0 DRIVEN DEPTH OF GROUT SEAL <br />0 OTHER GROW' SEAL INSTALLED BY <br />DIA. OF CONDUCTOR CASINO <br />(HA. OF WELL CASING <br />SPECIFICATION Ct. - <br />GROUT BRAND NAME i - 11- eakd <br />t..- <br />]c ' <br />AIDS <br />r7 4:7 t.ti <br />.4. <br />APPLICATION FOR WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />MAR 1 5 1999 ENVIRONMENTAL HEALTH DIVISION MAR 1 0 1999 <br />304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br />(209) 468-3420 vr LN AL HEALII <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT / SERViCE <br />(Complete lo TripHeats( <br />APPLICATION IS 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 />JOAOUIN COUNTY DEVELOPMENT TITLE. CHAPTER 9-1116.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR APNO 2• 14 V- Wel Ot4 104 h 5 L• - <br />CITY ?t1.N PARCEL SIZEJAPN/ <br />OWNER'S NAME L !lay oRufroie r 7..c.c v. 54114ais ADOREgglAo3 W. L. id 12,0 ptioNE,475 s 3 s00 <br />..t CONTRACTOR 1,01,tilt(445( 640 r-PilttolirOkittetollqiiIPIL- ADDRESS Pic° 5- A/- 14/c I fo Ivg, 40 74- 7 pHONE ,L167-i006 <br />SUB CONTRACTOR 0 re kt <br />ADDRESS uc,t;72,61 pliN41-460 <br />o REPLACEMENT WEU. <br />0 WEILL SYSTEM REPAIR <br />H.P. <br />1:1 OUT-OF-SERVICE WELL <br />TYPE OF WELIJPUMP; 0 NEW WELL <br />0 INSTALLATION <br />0 New 0 Reps* <br />(TYPE OF PUMPI <br />MONITORING WELL <br />CROSS-CONNECT REPAIR <br />DEPTH PUMP SET FT. <br />GEOPHYSICAL WELL <br />0 <br />A <br />0 DESTRUCTION: <br />tig MONITORING GROUT SEAL PUMPED: By. Owe CONCRETE PEDESTAL BY DRILLER: 0 Yee No <br />APPROX. DEPTH .3 <br />a. <br />17 LOCKING CHESTER BOX/STOVE PIPE <br />PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER )1\ CABLE OTHER <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATION AND THAT THE WOW 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 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 CALIFORNIA. CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED. I SHAU. EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CALIFORNIA.' THE APPUCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12001 41111.34211, COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />RWIW X t/<- Pita;4' Title 3.146'c JJc,C,i' 6 ve iCy;' 4 T Dote 5W , <br />PLOT PLAN (Draw to Seale) Scala to <br />I. 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 /> <br />LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM on 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 />. ...... . <br />7 ) <br />Apr:one:odor' Accepted By <br />Grout IropectIon By <br />Dootructlen Inspection 8 <br />Comments: iretrY1 <br />ACCOUNTING ONLY: <br />0-0 5 Vé 1(44 V. s <br />, <br />14/4' r.e 4 (c tc <br />FACO <br /> <br />DEPARTMENT USE ONLY <br />Dots 3/,.c/ff Liz 0 <br /> <br />(1h I DM* <br /> <br />Pump Impaction By <br /> <br />Dote <br /> <br />A 2 s•ctdr 192 C)c or .-(-y)-j. <br />PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECO", II DATE . PERFAIT/SERVICE REQUEST NUMBEFI INVOICE <br />3 50 I eci 00 /NI- I iei- 3715-Af ei sc; 00 <br />SROS \ qto 00 <br />Pub Health Serv. - Enviro. 173 (1/97)