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APPLWATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201.388 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICompleb in TriPl•Innl <br /> APPLICATION 16 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE MW DESCRIBED.THIS APftJCATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-11'S.3 AND THE STANDARDS OF SAN JOAQUIN COU HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> W' chQ,- f Ld Cm, J`H•f••J PARCEL SIZEJAPNJ {{�_ <br /> JOB ADORESSION APNJ ry�,y1 I/] y C � ;7��� t [!]wi OlL!��c)+ PHONE I�Ii <br /> OWNER'S NAME -LO 'pIt/L.1U //J`J �� ar AOORESSa"55J0-yV�[(�-CA 1 Q C�/ / �ry� <br /> COMPACTOR I ��[ <br /> .-. prllirnl LlgggL]L ADDRESS()jk1El3&lIL/D�LS 2('1 UCiJJ'IG PHONES 7E/ <br /> ADDRESS UCe PHONE I <br /> SUBCONTRACTOR <br /> ❑ OTHER <br /> ryPE OF WELLPUMP: ❑ NEW WELL ❑ REPWCEMENT WELL ❑ MONITORING WELL A <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION///�W//Ey�LLk <br /> ❑N.❑Rep.lr H.P. <br /> DEPTH PUMP SET_�FT. <br /> FIRST WATER LEVEL -A L O <br /> SOIL BORING(TYPE OF PUMPI 13OUT-OFSERVICE WELL HY <br /> ❑ GEOPSICAL WELL/ <br /> S <br /> ❑DESTRUCTION: A <br /> TYPE OF WELL CONSTRUCTION bPFCIFlCATONS ; OIL A. G <br /> INTENDED USE DIA.OF CONDUCTOR CASING /T <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION �J`1 O <br /> TYPE OF CASINGISTEEU C Y V ( DIA.I F WELL CASING <br /> DOMESTICIPNVATE Cl GRAVEL PACK/SIZE SPECIFICATION R <br /> ❑ PUBUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL <br /> GROUT SEAL INSTALLED BY Ilp SMUT BRAND•'•••`�•.�/1NL f <br /> ❑ IRPoGATIONIAG OTHER GROUT SEAL pUMPED:gYs ❑Ne CONCRETE FEDESTAL BY I)MLLFR:❑Yr ❑Na S <br /> ❑ MONITORING <br /> +} ,T LOCKING CHESTER SOXISTOVE RPE ` <br /> APPIIOX.DD H AUGER X CABLE OTHER <br /> PROPOSED CONBTRUCTIONNW RIND METHOD: MUD ROTARY <br /> AIR ROTARY <br /> HEREBY CERTIFY THAT"AVE PREPARED THIS AFRJCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. NOME OWNER OR LICENSED AGEM'S SIGNATUiiE CERTIFIES THE FOLLOWING:•I CERTIFY THAT IN THE PERFORMANCE OF THE WOW(FOR WHICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMROY PERSONS SUBJECT TO WORKMAN'S COMFENGATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CCT To WORM",OONU�ENSAnONERTIFIES C <br /> THE M CH <br /> HIS KWff <br /> CAUFORNIA.•NTHF I CERTIFY P CANTTMUST C/TA{}HJ�E= FORMANCE OF THE WOW MR HOURS N ADVANCE FOR ALL REQUIREDTINSPFCTIONS AT(200) <br /> A1eSJe3SMCOMPIEKOY TE DRAWING AT LOWER AREA WtOVIDEDi_ ^�LAWS OF el <br /> .{� nn. L' OS/ / D.I. <br /> same x v <br /> MAT PLAN IDrnv la be4e1 Sul. •I° <br /> A. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPO <br /> 1. SED <br /> NAMES Of STREETS OR ROADS NEAREST TO OR BOUNCING THE PROPERTY. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> I. OUTLINE OF THE PRDPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. SLL EXISTING . LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL AND PROPOSED ON THE PROPERTY OR ADJOINING PROPERTY- <br /> STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS,AND WAUCS. <br /> ElA. <br /> DEPMTMENT USE ONLY � I. <br /> Del.m A,r o <br /> aq <br /> ApPllutlen Accepbe B D.I. <br /> D.le Pumpinpectlon BY <br /> Grout lm,,Uon By D.le/' <br /> Om<,uclion InP«lion BY _ ,Vlmp%lion BY /��-�I� �� 4,19 <br /> Commmb: •� Ro EDD //TTJNA// <br /> FAC+ <br /> ACCOUNTING ONLY: AIDE <br /> DATE <br /> CHECUICASH RECEIVED BY <br /> PDIMITISERVICE REGUE6T NUM6ER INVOICE <br /> m CODES FEE INFO AMOUNT REMITTED <br /> it <br /> 5o i YvJ 11 1 <br />