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APPLICATION FOR WELLIPUMP PERMIT -�— <br />'31AN JOAOUIN COUNTY PUBLIC HEALTH SERV[ <br />ENVIRONMENTAL HEALTH DIVISION <br />F 0 00X 388, 446 N. SAN JOAOUIN ST., STOCKTON, CA 96201.388 <br />{2091488.3420 �? <br />_ (Cessplets is TFIPrMte) ' <br />`--, Application is here by made to the San Joaquin County for a permit to construct and/or <br />made.in compliance with San Joaquin County Development Title, Chapter 9-1115.3lajd tI <br />services, EnvirormentaL Health Division. wJob Address/or APN#. E Z3 57 FO -2.+ NW � � City <br />Owner's Name .L.�C_ SI• ru icA. �. Addr... (4) g,kslac— 1iC2r <br />install the work described. This application is <br />Standards of San Joaquin County Public Health <br />Parcel Size/APN# <br />Phone #21,06,31-20 0 1 <br />Contractor_�Q�,.�e11ty. <br />121SkEL.;A&A_ <br />Address 17W75 Vby-, t0k <br />Lic# Phone #(714)V o. -777o 1 <br />l n <br />JA(A?,r,O� � r;I�1V <br />1� <br />Address �33FtSS...e,,lot Sat • iI, <br />C-57 <br />Lic# 55y979 Phone #W4 J 438-]27(s <br />Sub ContractorWe.5+ <br />TYPE OF WELL/PUMP: <br />[I NEW WELL 0 REPLACEMENT <br />�T <br />WELL [) MONITORING WELL.I# <br />�i <br />0 OTHER <br />DESTRUCTION 0 OUT -OF <br />-SERVICE WELL [I GEOPHYSICAL WELL # <br />❑ SOIL BORING <br />p INSTALLATION [I WELL <br />SYSTEM REPAIR ❑ CROSS -CONNECT REPAIR <br />[I VAPOR EXTRACTION WELL # <br />[I New ❑ Repair H.P. <br />} <br />DEPTH PUMP SET <br />FT. FIRST WATER LEVEL <br />(TYPE Of PUMP) <br />INTENDED USE <br />TYPE OF WELL <br />CONSTRUCTION SPECIFICATIONS <br />[I INDUSTRIAL <br />[I OPEN BOTTOM <br />DIA. OF WELL EXCAVATION i' <br />DIA. OF CONDUCTOR CASING <br />(I DOMESTIC/PRIVATE <br />[I GRAVEL PACK/SIZE <br />TYPE OF CASING/STEEL/PVC '+ <br />DIA. OF WELL CASING <br />[I PUBLIC/MUNICIPAL <br />[I DRIVEN <br />DEPTH OF GROUT SEAL I'' <br />SPECIFICATION <br />❑ IRRIGATION/AG <br />[I OTHER <br />GROUT SEAL INSTALLED BY 11 <br />GROUT BRAND NAME <br />MONITORING <br />GROUT SEAL PUMPED: ❑ Yes [I No <br />CONCRETE PEDESTAL BY DRILLER: [I Yes ❑ No <br />APPROX.OEPTH <br />LOCKING CHESTER BOX/STOVE PIPE <br />'PROPOSED CDMSTAUCTIONIDRILUNG METHOD: MUD ROTARY_ <br />AIR ROTARY„ AUGER_ ,CABLE_ <br />OTHER T <br />1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, <br />State Laws, and Rules and Regulations of the San Joaquin County. Home owner or; licensed agent's signature certifies the. following: "I } <br />certify that in the performance -of -the work for which this permit is issued, I shall not employ persons subject to WORKMAN'S COMPENSATION JI <br />Laws of California." tractorls hiring or sub -contracting signature certifies the following: " 1 certify that in the performance <br />of the work for ch this permit ss I s all employ persons subject to WORKMAN'S COMPENSATION Laws of California." THE APPLICANT <br />MUST CALL 24JORS,1111 ADVANCE FO AL UUTAE PECTIONS AT (209) 4W3423. Complete drawing at lower area provided. j <br />Signed <br />PLOT PLAN (Draw to Scale) <br />1. Names of streets or roads nearest to or bounding the property. <br />2. outline of the property, giving dimensions and North direction <br />3. Dimensioned outlines and location of all existing and propos <br />structures, including covered areas such as patios, driveways, <br />and walks. SEE ATTPc..ti�(� Mp►P <br />Application Accepted I <br />,j <br />!L Title„` `'� Oat e_5X� <br />S <br />Scale h �� to <br />I'Ir 4. :h Location of house sewage disposal system or <br />If proposed expansion of sewage disposal systems. <br />ed { 5. Location of wells within radius of 150 ft. on <br />..the property or adjoining property. <br />t <br />Grout Inspection By> Date Pump Inspection By Date <br />Destruction Inspection By Date ZS Comments: <br />IE I <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES FEES AMOU/N,T, REMITTED CHECNOICASH RECEIVED BY DATE I J�PERMITISEAVICE REQUEST NUMBER INVOICE <br />�INF0 <br />,F <br />