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APPLICATION FOR WELLIPUMP PER <br /> r ''t^ SAN JOAOUIN COUNTY PUBLIC HEALTH,SE VICEtENVIRONMENTAL HEALTH OIVISl11N <br /> P O 80X 385,446 N.SAN JOA411IN ST,STOCXIOM,CA i62ol-385 NA ( `U <br /> [Z091 488 m O 1 <br /> AON•REFUNDABLE PERMIT EXPIRES 1 YEAR FROM OA7 IYSUEO <br /> ICamPMu 4 TriNBaary OL <br /> Application is here by made to the San Joaquin Canty for a permit to construct a�d/or install the wort described. This app,Ieation is <br /> made In compliance with San Joaquin Canty Development Title, Chapter 9-1115.3 and the Standards of San Joaquin Canty Public Health <br /> Services, Environmental wealth Division <br /> .7� S{ 11 /1f- <br /> Joh Address/or APNA! 1vd% �, r city J��IrJJ�7Y— <br /> �,ri� / Psrcel S,2e/APN/ / u �/ <br /> Owner's Name= I�t¢�1n21,p _ Phone 8644179 fC.j 1 313 <br /> /s 1�Address <br /> L Caneraeeer i Q U iD.'t%p�S J Address <br /> eke r/ p' /. Phone /�`p!_�� <br /> F <br /> iwb Contractor-A 7 Address S� ,'+/K Ica cfI /(y lfi j3 Phoma #_21-S ,�CZ <br /> TYPE G WELL/PUMP, E] NEW WELL p REPLACEMENr VELI. R MONITORIMG WELL X - -n OTHER <br /> I] DESTRUCTION p OU <br /> T-OF-SERVICE WELL 11 GEOPHYSICAL!WELL NQ <br /> X SOIL BORING d ^2C) <br /> I it INSTALLATION Q WELL SYSTEM REPAIR 13 CROSS-CONNECT REPAIR, (I VAPOR EXTRACTION WELL / <br /> (TYPE OF PUMP) 11 Now p Raps Ir N.P. DEPTH PUMP'SET" FT. FIRST WATER LEVEL <br /> MENDED USS TYPE OF WELL CONEIRUCTION SPEC)FICAYIOHY <br /> INDUSTRIAL E1 OPEN BOTTOM DIA. OF WELL EXCAVATION _715� '=DIA. OF CIINOUCTOR CASING <br /> E1 DOMESTIC/PRIVATE (1 GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC .Il DIA. OF WELL USING - <br /> 11 PUBLIC/MUNICIPAL E] DRIVEN DEPTH OF GROUT SEAL II SPECIFICATION <br /> E1 IRRIGATION/AG OTHER f GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> �k El MONITORING GROUT SEAL PUMPED: E3 Yes (1 No CONCRETE PEDESTAL BY DRILLER: Q Yes 11 No 4 <br /> APPROX.DEPTH �S Y-C LOCKING CHESTER BOOP/STOVE PIPE 0 t <br /> � PROPGSED CONSTRUCTIOIUDRILLING METHOkk ROTARY AIR ROTARY AUGEA_�K` CABLE <br /> OTHER_ ` <br /> I hereby-certify the have prepared this AMLication and that the work lkI be done iiiaccardance with Sen Joaquin County Ord, as, <br /> State Jaws, and Rules find Regulations of the San Joaquin County, Noma owner or Lie'ensed agent's signature certifies the following: •[ <br /> certify that in the performance of the work for which this permit is issued, I shall not mplay persons abject to WORKMAN#S CC14PENSATION <br /> Laws of Califarnia.o Cantraetor•s hiring or sub-contracting signature cartifie2 the following: N I Certify that in the performance <br />( <br /> of the work for which this permit is issued, I sheik employ persons abject to WOXKAN$S COMPENSATION Laws of California." THE APPLICANT <br /> MUST CALL 24 HOURS IN ADVANCE FOR ALL RENE=INGPEBTIORB AT 1206)400.2427. Complete drawing at tower area provided. /' - <br /> Signed X I�Titte F // <br /> A04anAGs],rc�4 Date / :FAEP <br /> Y _ PLOT PLAN Draw to Scale) Scale' to <br /> . . -= <br /> t. and North direction. Ij proposed eNames of streets or roads nearest to or bounding the property � L. location of home serape disposal system or <br /> 2. Outline of the property, giving dimensionsxpansion of sewage disposal system. <br /> 3. Ofaiensioned outlines and Location of ail existing and proposed 5. Location of wells within radius of 150 ft• on <br /> sand ct res, Including covered arm such 44 patios, sways, `1. th`proopetty or adj fining property. <br /> r .QR S [ <br /> 3 � <br /> If I 1 + <br /> i <br /> a I l •- <br /> i <br /> 3 <br /> i <br /> 4 <br /> 11 <br /> !Y <br /> I� <br /> EPARTM U E ONLY I <br /> a <br /> AppiicIrian Accepted BY! ' - Date '�L ArtE <br /> ele <br /> Grout Inspection By �^-'LA,& � \V'�l�^-� Date Puny Inspectian.BV Date <br /> Destruction Inspection By - Date Comments: i! <br /> 0 <br /> II <br /> - ACCDU[T[[Q ONLY: ATOM FACE <br /> PE CODER FEE INFO AMOUNT REMIT11-0 CHELDUOCASH RECEIVED BY DATE I'i PEAM,TIYERVICE REQUEST NUMBER INVOICE <br /> t <br /> l <br /> I, <br />