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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388,904 EAST WEBER AVENUE, STOCKTON, CA 55201.388 <br /> (209) 488.3420 <br /> MON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> II:SBIpbte In TripketB) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-11115.3^AND <br /> /THE <br /> �STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOBADDRESSORAPN# r136l t—i I'lo,4 �f//Q CITY�7p�Lzp PARCEL SIZE/APN# ��/�(�'] <br /> OWNER'S NAME • ,//JFl7CijHl UGC// /J/L J�� ADDRESS X�7711, r �7 �Z1,S� ��PHONE#Zji� J /6/p <br /> CONTRACTOR 1N1 B nky,j u w, ADMSB�jLU CS F1?6 0ff1'7 LLIC# Off PHONE# <br /> SUB CONTRACTOR l , ADDRESS S—r<00u F5,215— IJCI PHONE/ <br /> TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER <br /> St/ <br /> n ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION/WELL# J <br /> St[dYrIPR-Sl�, ❑NewMRapair H.P. DEPTH PUMP SET�ZFT. FIRST WATER LEVEL 4 � d <br /> ITYPE OF PUMP) <br /> 61�F P ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING g <br /> DON: W <br /> NON <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑�..,, INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO p(T� <br /> W'60MESTIC/PIUVATE ❑GRAVEL PACKISIZE TYPE OF CASING/STEEUPVC DIA.OF WELL CASINO D <br /> ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E r <br /> ❑ MONITORING GROUT SEAL PUMPED: ❑Yes ❑No CONCRETE PEDESTAL BY DRILLER:❑Yes ❑Ne S <br /> APPROX.DERVLOCKING CHESTER BOX/STOVE PIPE S <br /> PROPOSED CONSTRUCTION/ORIWNG 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:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW 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 THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' CANT MUST CALL St HOURS IN AD NCE FOR ALL REQUIRED IN=.* <br /> >f. C PLETE DRAWING AT LOWER AREA PROVIDED. (� ` <br /> Signed X TitleData /2^/['�J✓, <br /> PLOT PLAN(Draw to Scale)S"Is 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. !. LOCATION OF IGOUSE 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 EX19TINO AND PROPOSED E. 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 /> ........All,........... .. <br /> .. <br /> .. <br /> 11 <br /> b 1 A t� <br /> . ... <br /> \.J . <br /> _. <br /> ACS 1 1 1996 <br /> . <br /> DEPARTMENT USE ONLY <br /> Application Accepted BY to, I Al <br /> Grout Inspection BY Date Pump Inspection By ` Date d <br /> Destruction Inspection By Date <br /> Comments: <br /> ACCOUNTiNO ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CH /CASH RECEIVED BY DATE P9IMITISER/ICE REQUEST NUMBER INVOICE <br />