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0 NEW WELL El REPLACEMENT WEU. 0 MONITORING WELLS 0 OTHER <br />El INSTALLATION 0 WELL SYSTEM REPAIR ID C11099-CONNECT REPAIR 0 VAPOR EXTRACTION WELL S <br />0 New 0 Repair H.P.FIRST DEPTH PUMP SET FT. WATER LEVEL <br />0 OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELLS (I.S;411. BORING $ <br />TYPE OF WELUPUMPt <br />(TYPE OF PUMPI <br />joGA <br />ank <br />f-toPb 10 1 <br />DEPARTMENT USE ONLY <br />Purnp Inspection By <br />Deis 7r77 <br />Date <br />Appllo•Pen Parmelee! By <br />()rout Inspection By <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 />NOWREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Memphis he TrIpReatel <br />APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED. TI118 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 AMU/ 513 See-16/43 goAci crry STO C.- k-77)10 PARCEL SIZEMPNE <br />OWNER'S NAME (eep) DeA4 TAIJSsen) ADDRESS $.4- 5(6 Se-010)N) k0/41:1 PHONES <br />CONTRACTOR ACIv/wcz-p 6, et) LuthronwcA7174-1---,r-A)c___, ADDRESS +005 A).0;/so/J UCE 61g02.1 7 PHONE S 4-67-100(o <br />SUB CONTRACTOR 6214 r'•'/V. ADDRESS -564 rut.*1: ibl'• LICE PHONE 44142)386 —22.22 <br />0 DESTRUCTION: <br />INTENDED USE TYPE OF WELL <br />INDUSTRIAL <br /> <br />0 OPEN eorrom <br />DOMESTIC/PRIVATE <br /> <br />0 GRAVEL PACK/SIZE <br />PUBLIC/MUNICIPAL <br /> <br />0 DRIVEN <br />IRRIGATION/AG 0 OTHER <br />MONITORING <br /> <br /> / , A / <br />APPROX. DEPTHAto P. I ) 66 -eV 30 <br />PROPOSED CONSTRUCTION/DRILUNG METHOD: MUD ROTARY <br />CONSTRUCTION SPECIFICATIONS <br />A DIA. OF WELL EXCAVATION DIA. or CONDUCTOR CASING 0 (eQ <br />TYPE OF CASING/STEEL/PVC DIA. OF WELL CASINO <br />D DEPTH OF GROUT SEAL SPECIFICATION R <br />GROUT SEAL PUMPED: Dye. ON. CONCRETE PEDESTAL BY DRILLER: 0 Yea ON. $E 60.1 <br />GROUT SEAL INSTALLED BY GROUT BRAND NAME POY-1-1/41108. <br />LOCKING CHESTER BOX/STOVE PIPE <br />AIR ROTARY AUGER CABLE OTHER <br />(-31 <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 LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH <br />THIS PERMIT 18 ISSUED, 1 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 PERFORIVIANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CAUFORNIA.• THE APPUCANT MUST CALL 24 HOURS IN ADVANCE FOR AU. REQUIRED INSPECTIONS AT 12091 4119-3423. COMPLETE DRAWING AT LOWER AREA PROvomo. <br />Starved X Ageb**,‘".1fri-.._ Title .e...a/f1Si (An Artra-ec1 Date 0001 <br />PLOT PLAN (Draw te &Wel Sadie <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 OUTUNFS AND LOCATION OF ALL EXISTING AND PROPOSED <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. <br />to <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;a_ A1,4p 0A) <br />• <br />....... <br />... <br />01‘41-1 17)A-A_.) , <br />... <br />Dertruction ImpectIon By <br /> Dote <br />Comment*, <br />ACCOUNTING ONLY: AIDS FACE <br />PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBEF1 INVOICE <br />W 4 9? ' $ q,6 -/..s,AS etAne f_i;i,ZO 9 in?' <br />Pub Health Serv. - Enviro. 173 (1/97)