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APPLICATION FOR WELLIPUMP PERMIT PAYMENT <br /> •SAN JOAQUIN COUNTY PUBLIC HEALTH SERs RECEIVED <br /> ENVIRONMENTAL HEALTH DIVISION U(Z Z 4 M1�f S <br /> P,O, BOX 988 904 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br /> (209) 468-3420 SANT �C)UPJ7Y <br /> PUBLIC:HEALIH SERVICrS <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONNIDI I)Ai-H All'r1 C!V!SION <br /> ICompletE In Tripl'ientE) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SA <br /> JOAQUIN COUNTY DEVELOPMENT TITLE. <br /> CHAPTER 9-1115.3 AND At <br /> STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESB/OR APN# L„Y U CA� 1.fC O rj/ 4C,A CITY <br /> p1 <br /> �PARCFL SIZE/AM# <br /> OWNER'SNAME R1L qA0 GgKDl ADDRESS vQ, LnPHONE# JO7?-;3r <br /> /— <br /> • <br /> CONTRACTORA.G./ ADDRESS G3 ` . Y7Z5 HONE# 56 0 <br /> SUB CONTRACTORdq'J GADDRESS(✓ ZZFI /�--k��'�ICI 4�7�k11 PHONE I�IY�&S ZIS.' <br /> T y' <br /> TYPE OF WELLIPUMP: X4 NEW WELL 13q <br /> REPLACEMENT WELL MONITORING WELL# M IIIIIJ ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP) 13vS <br /> Naw❑Racal, H.P. DEPTH PUMP SET—FT- FIRST WATER LEVEL t Ln' <br /> ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ SOIL BOMNO $ <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS!., q <br /> 11INDUSTRAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING_ D <br /> 11RA <br /> DOMESTW/PRIVATE GVEL PACK/81ZE TYPE OF CASINO/STEEL/PVCp_r V`(-, DIA.OF WELL CASING 211 C <br /> ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEALF)F)�SA 'F O �, S4 SPECIFICATION EA IE L O R <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY OR: Int.r GROUTBRANDINAMELEJ10,1a <br /> Ip14 E <br /> J9 MONITORING ..Y3 I c GROW SEAL PUMPED: RYs ❑No CONCRETE PEDESTAL BY DRILLER:MY. Nv S <br /> APPROX.DEPTH 25 'F& - &s(f LOCKING CHESTER SOX/STOVE PLPE_j&&LLyGA (SOI( S <br /> PROPOSED CONSTRUICTIONRNSWNO METHOD: MUD ROTARY AIR ROTARY AUGER_CABLE OTHER <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES ANI <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICI <br /> THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFOMIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CEWIFIE' <br /> THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS 0 <br /> CALIFORNIA.- T E APPLICANT/Ill CALL <br /> I/2`44 H.D o IN ADVANCE FOR ALL REOMM INSPECTIONS AT 1201111 481-1.111. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> SISmEX � 1) W�JI Tltla �QGIDSI�I I Data QI6.y�T <br /> PLOT PUN#Draw to Sva1e)Scale 'to <br /> 1. NAMES OF STREET$OR ROADS NEAREST TO OR BOUNDING THE ROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION Of SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY IT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> DEPARTMENT USE ONLY 7 <br /> Application AvvWted BY q Data ` Orae Groin Impavtlon By Data ! Nino Impction BY Data <br /> De.lruetlen Inapctlon By <br /> Data <br /> Commeae: <br /> ACCOUNTING ONLY: AID# FACP <br /> PE COOU FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED SY BATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />