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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERI 1 <br /> ENVIRONMENTAL HEALTH DIVISION PAYI;,ENT <br /> P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201.388 RECEIVED <br /> (209) 468.3420 J U N % <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN <br /> (Complete in Triplicate) RR���P�pUE3LuII�CHE E5 <br /> Application is here by made to the San Joaquin County for a permit to construct and/or install the woEW VAQN9&YT#ftis applic'sti,9,91 <br /> made in compliance with San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br /> Services, Environmental Health Division. -DI1?—GC7" SO,UI j�}}��pF ,l¢Ol i �G�Ly 1NJ <br /> J 5� <br /> / <br /> job Address/or APN# d"r l � � City � arcel <br /> Owner's Name �Z Address C,l Phone # Q <br /> Contractor Address / / >�E'F!// L� Lic# Phone <br /> Sub Contractorls�yl 5;(1f Addres3 _ „ Lic# Phone# 2aS 727/ <br /> TYPE OF WELL/PUMP: WINEW WELL ❑ REPLACEMENT WELL U.-90—NITORING WELL ## [I OTHER <br /> [I DESTRUCTION [I OUT-OF-SERVICE WELL [I GEOPHYSICAL WELL # [) SOIL BORING <br /> [) INSTALLATION [) WELL SYSTEM REPAIR [I CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL # <br /> [I New ❑ Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 6/ <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Il <br /> [I INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WELL EXCAVATIO DIA. OF CONDUCTOR CASING <br /> [] DOMESTIC/PRIVATE L"RAVEL P K S d• QTYPE OF CASING/STEE P DIA. OF WELL CASING �� 7 <br /> (I PUBLIC/MUNICIPAL [) DRIVEN DEPTH OF GROUT SEAL .Sci✓ SPECIFICATION _ <br /> IRRIGATION/AG ❑ OTHER GROUT SEAL INSTALLED BY S GROUT BRAND NAME <br /> MONITORING GROUT SEAL PUMP (I Yes dYlfo CONCRETE PEDESTAL BY DRILLER: [I Yes LI-WoAPPROX. DEPTH LOCKING CNE ER 8 /STOVE PIPE <br /> PROPOSED CONSTRUCTIONIDRILLING METHOD: MUD ROTARY_ AIR ROTARY_ AUGER CABLE_ OTHER_ <br /> I 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 <br /> Laws of California." Contractor's hiring or sub-contracting signature certifies the following: 11 1 certify that in the performance <br /> of the work for which this permit is issued, I shall employ persons subject to WORKMAN'S COMPENSATION Laws of California.11 THE APPLICANT <br /> MUST CALL 24 HOURS IN ADVANCE FOR AkL REQUIRED INSPECTIONS AT(208)488.3423. Complete drawing at lower area provided. ' <br /> T i t l e C-7;0 LDate <br /> S T <br /> Signed X <br /> PLOT PLAN (Draw to Scale) Scale 11 to_ <br /> 1. Names of streets or roads nearest to or bounding the property. 4. Location of house sewage disposal system or <br /> 2. Outline of the property, giving dimensions and North direction. proposed expansion of sewage disposal systems. <br /> 3. Dimensioned outlines and location of all existing and proposed 5. Location of wells within radius of 150 ft. on <br /> structures, including covered areas such as patios, driveways, the property or adjoining property. <br /> and walks. <br /> Mill <br /> r lilt, <br /> DEPARTMENT USE ONLY <br /> Application Accepted By �/�" �w Date 0 Area <br /> Grout Inspection By Date Pump Inspection By Date <br /> Destruction Inspection By Date Comments: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#1CASH RECEIVED BY ERMITISERVICE REQUEST NUMBER INVOICE <br /> U <br />