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APPLICATION 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 95201.388 <br /> (209) 488.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Compl9t9 in Triplint9) <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 SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE <br /> /:A7NARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESS [ <br /> OR APN# 1 ( D / `J�� /T ` CITY S/ O C� O Q �—� PARCEL SIZE/APNN <br /> OWNER'S NAMEeu r ADDRESS o7A.. PHONE# <br /> CONTRACTOR ADDRESS `0�2 LICN.J:�24XIQ PHONE L <br /> SUB CONTRACTOR ADDRESS LIC# PHONE# <br /> TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL BY EM REPAIR ❑ CROSS-CONNECT REPAIR 13 VAPOR EXTRACTION WELL# J <br /> y� ❑NewoRepair H.P. � DEPTH PUMP SET VT. FIRST WATER LEVEL O .� <br /> (TYPE OF PUMP) —� <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING 8 <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D <br /> ADOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEUPVC DIA.OF WELL CASING D <br /> ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E' <br /> ❑ MONITORING GROUT SEAL PUMPED: ❑Y. [IN. CONCRETE PEDESTAL BY DRILLER:❑Yes ❑No S <br /> APPROX.DEPTH ®O LOCKING CHESTER BOX/STOVE PIPE S� <br /> ;2- <br /> PROPOSED CONSTRUCTION/DRILLING 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 AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENS ON LAWS OF <br /> CALIFORNIA." T CANT MUST CALL 24 IN AD NCE FOR ALL REQUIRED INNS AT(20914093429. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Signed X Title `` ��f S' Date <br /> PLOT PLAN(Draw to Solve)Scale "to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 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 FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> . <br /> . .. <br /> . .. <br /> . ... <br /> . <br /> _ - ,- <br /> _. . <br /> 1 <br /> .... <br /> ym <br /> .. <br /> Pa: <br /> 1f.C95 <br /> — — -- <br /> . <br /> . <br /> i_ .. r <br /> .. : .. }t <br /> SL 1 I <br /> �� F <br /> .�i��.:i FJ fir! <br /> .. .. ✓ .. ✓ti..� .. .. <br /> f <br /> �1 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By aq-b Ares <br /> Grout Inspection By Date Pump Inspection By yCwwx9f6C Dats <br /> Destruction Inspection By Date <br /> Comments: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED /CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> D b b <br />