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1 • <br /> • r <br /> APPLICATION FOR WELUPUMP 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 /> (Campi$t$iI TTipDeat$) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-111 5.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESS/OR APN/ 13737 S. AIRPORT WAY cm MANTECA, CA 9 5 3 3 6PARCEL SIZE,APN,1 98-03-03 <br /> OWNER'S NAME r TIF 3RnnT R. OWNS —C? ADOREsS908 RTTRY CT f RTPnN, CA PHONE x209-471 –1 78 <br /> ADDRESS PO BOX 51 uC. 720904P„ONER 707374281 <br /> CONT RACTOR� [�i T1RTT T TRIC TRIC E RIO VISTA, CA 945 1AGOWPHONE <br /> SUB CONTRACTOR <br /> TYPE OF WELLMVMP; ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL NN ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ ✓ <br /> ❑Na-❑Repalr H.P. <br /> DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> (TYPE OF PUMP) 0 SOIL BORING 4 S <br /> ❑ OVT-0E-SERVICE WELL ❑ GEOPHYSICAL WELL# <br /> ❑DESTRUCTION: ITH NEAT CEMENT GROUT AFTER SAMPLING <br /> A <br /> INTENDED USE TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D <br /> [jDOMESTIC/MVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEEVPVC DIA. F WELL CASINO O <br /> ❑ PUSLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION S <br /> ❑ IRRIOATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITORING GROUT SEAL PUMPED: [Iyea [IN. CONCRETE PEDESTAL BY DRILLER:ClYaa El N. 5 <br /> LOCKING CHESTER BOX/STOVE PIPE 5 <br /> APPROX.DEPTH GEOPROBE <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MVD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HE9EBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOFK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAOVIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT 18 ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUS-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' THE- PPUCANT MUST C 21,17 1N ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12001400-31,423. PL <br /> • COMETE DRAWING AT LOWER AREA PROVIDED. <br /> ' t <br /> Btar»d X l Tltla <br /> Date <br /> PLOT PLAN BA aw 1e Soalel Scala 'to <br /> 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 2. OUTLINE OF THE POOPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. S. LOCATION OF WELLS WITMN RADIUS OF ONE HUNDRED FIFTY FT. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTIIO AND PROPOSED ON THE PROPERTY OR ADJOINMG P"O ERTY. <br /> STRUCTURES,04CLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. <br /> .... ....... .. .......... <br /> "PMTMEFIT USE ONLY <br /> Application Aeoepted By <br /> O—A Impxtlen By Date Pump I—p—tlen By Date <br /> Data <br /> Deslnretlen Inspeelbn y <br /> Comments: <br /> ACCOUNTING ONLY: AID/ FACT <br /> PE CODES FEE INTO AMOUNT REMITTED CHECK//CASH RECEIVED By DATE PERINIT/SERVICE REQUEST NUMBER INVOICE <br />