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APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 �j <br /> (209)468-3420 l j Z �� / <br /> PL-V„*4 oc-, NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED -2- <br /> (Complete M TripReatel <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.TR118 APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115 3 THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DMBION. <br /> JOB ADORESSIOR APN#_- / (� CITY `�� _PARCEL 81ZE/APN# <br /> OWNER'S NAME Al, ADD10E88 ✓y►• PHONE# <br /> CONTRACTOR Of LG_f � (� .z) � �.//_ ADDRESS T LK:612aY,2 PHONE <br /> SUB CONTRACTOR ADDRESS LOCO PHONE# <br /> TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER <br /> ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELLI J <br /> El I4,I Repent ".P. 2= DEPTH PUMP SET�Fr. FIRST WATER LEVEL ��� O <br /> RYPE OF PUMP) <br /> ❑ OUT-OF-9ERVICE 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 CASINO D <br /> O'OOME8TICIPRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEEL/PVC DIA.OF WELL CASINO p <br /> ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ IRRIGATION/AO ❑OTHER GROUT BEAL INSTALLED BY OROUT BRAND NAME E <br /> ❑ MONITORING GROUT SEAL PUMPED: ❑Yr (IN. CONCRETE PEDESTAL BY DRILLER:❑Y. (IN. S <br /> APPROX.DEPT" LOCKING CHESTER BOX/BTOVE PIPE S <br /> PROPOSED CON8TRUCTION/DRILUNG 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,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 DI THE PERFORMANCE OF THE WORK FOR WHICH�+ <br /> THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE RFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMP RATION LAWS OF t� <br /> CAUFO ANT MUST CA 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT(2081440-3422. COMPLETE DRAWING AT LOWER AREA PROVIDE !J <br /> 8ynstl X Title RIPZ Date Q <br /> PLOT PIAN IDr•w to Soel•1 SeeN "to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNOING 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 8. LOCATION OF WELLS WITHIN RAM11 OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED ARIEA$OWN AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> IVE <br /> _92000 <br /> OUIN COUNTY <br /> P EALTH SERVICES <br /> IL ENVIF.i .K TAI WPAITH f) <br /> DEPARTMENT WE ONLY <br /> AppSe•tlen Aeeepled B T Oeb � <br /> Oreut Imtroetlen By Date Pt•np IraPeetlen By Oete �6 <br /> De•trtrctlen Inopectien 8 Dote <br /> Cemmente: <br /> ACCOUNTINO ONLY: AID# FACT <br /> PE CODES FEE INFO AMOUNT REMITTED HECK# ASH RECEIVED By DATE PER ITr8ERVICE REQUEST NUMBER INVOICE <br /> t $O gsv 03 1 <br /> Pub Health Serv.-Enviro.173(1/97) <br />