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APPLICATION FOR WELL)PUMP PERMIT <br /> N JOAQUIN COUNTY PUBLIC HEALTH SERVICE <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 98201.388 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete is Triplicate) <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 <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. C 1 - 1 I 1 <br /> Job Address/or APN#_ 53 S Ce-nie.,r 7T( e�"� City 1STVCJc-A- Parcel Size/APN# // <br /> Owner's Name 11'V � C Address 535 Ce,v�-t-er S k r¢,e - Phone # 97Z- /moo ) <br /> Contractor C VA2-M V--'t L, r^ �I Address /� Lic# Phone #'/ <br /> Sub Contractor SPP L-�"f l,tyv\ c7CR(OrcSOn Address 27J�a�we." D% Lic#J(/Z Z & $ Phone # ` (o 87 L2- <br /> TYPE <br /> ZTYPE OF WELL/PUMP: [) NEN WELL [I REPLACEMENT WELL 11 MONITORING WELL # `❑ OTHER <br /> 11 DESTRUCTION 11 OUT-OF-SERVICE WELL [1 GEOPHYSICAL WELL # 10 SOIL BORING l 'IU IO I <br /> INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR [1 VAPOR EXTRACTION WILL # <br /> New [1 Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> [3 INDUSTRIAL [I OPEN BOTTOM DIA. OF WI EXCAVATION t/ <br /> o DIA. OF CONDUCTOR CASING <br /> [IDOMESTIC/PRIVATE [I GRAVEL PACK/SIZE_ TYPE OF CASING/STEEL/PVC DIA. OF WELL CASING <br /> 0 PUBLIC/MUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL 2 5 ' SPECIFICATION //�� <br /> [3 IRRIGATION/AG [I OTHER GROUT SEAL INSTALLED BY See[ TUw�^ GROUT BRAND NAME_CErA .t 13C..Aio t C <br /> [1 MONITORING GROUT SEAL PUMPED: X Yes ❑ No CONCRETE PEDESTAL BY DRILLER: 11 Yes [I No <br /> APPROX. DEPTH LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTRUCTIONJDRILLING 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: 111 <br /> certify that in the performance of the work for which this permit is issued, 1 shall not employ persons subject to WORKMAN'S COMPENSATION <br /> Laws of California." Contractor's hiring or sub-contracting signature certifies the following: " I 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." THEAPPLICANT <br /> MUST OURS IN ADVANCE FOR ALL REQUIRED INSP,,EECTIONS AT 12051458.3423. Complete drawing at Lower area provided. <br /> i '1 q <br /> Signed %\ 1/Yt7 �,/'�, .011tCo1n'1v 1 Title ///r YIG�•Pir Date <br /> 61 <br /> PLOT PLAN (Drat o Scale) Scale 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 ppf all existing and proposed 5. Location of wells within radius of 150 ft. on <br /> structures, including covered ar ,4s such as patios, driveways, the property or adjoining property. <br /> and walks. SF A YlJ\ <br /> LL <br /> Awq <br /> yqxD PART T SE ONLY f�AppLicetion AcceptedBy LT Date VI �'7�Q�- �L1/. Area <br /> Grout Inspection By /y�(aCf/� Date (IZS Pune Inspection By Date <br /> Destruction Inspection By Date Cooments- <br /> ACCOUNTING ONLY: AID# FAC# 2wo <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH I RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> ,_ I bo ► I 5 <br />