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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOAQUIN ST, STOCKTON, CA 952UI.386 <br /> (209) 468-3420 i <br /> NON-REFUNDABLE PERMT EXPIRES 1 YEAR FROM DATE ISSUED ' <br /> mompwts In Tripliaai <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED,THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9.1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> JOS ADDRESSOR APN* r�w _. _CITY' 4ra� PARCEL SIZFIAPNir <br /> OWNER'S NAME,����y �/� _ __ ADDRESS PHONE! <br /> CONTRACTOR ucl an <br /> ADDRESS/(lJ LV r_ , PHONE I <br /> BUS CONTRACTOR ADDRESS <br /> TYPE OF WEILMUMP. ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL* ❑ OTHER <br /> • ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CPIOSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL* ✓ - <br /> ❑New❑Repels H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL D <br /> rTYPE OF PUMP) ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL• lialSOIL BORING S N <br /> ❑DESTRUCTION: ` <br /> INTENDED USE TYPE OF WELLCONSTRUCTION SPECIFICATIONS r A O <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION /• —_ DIA-OF CONDUCTOR CASING N D <br /> ❑ DOMESTICIPRIVATE ❑GRAVEL PACK1SiZE TYPE OF CABINGXMLIPVC DIA.OF WELL CASINGD <br /> ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT BEAL SPECIFICATION <br /> ❑ IRRIGATioNOAG OTHER�jr GROUT BEAL INSTALLED BY GROUT BRAND NAME ✓_ <br /> MONITOAING '�7D�� GROUT SEAL PUMPED: 13 Y.� CONCRETE PEDESTAL BY DRlUFR:❑Yee 13W S <br /> X.pFPTH ti✓ l LOCKINO CHESTER BOXISTOVE PIPEAPPROP5 <br /> PROPOSED CONSTRUCTIONIDWLLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> 1 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:'t 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 SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFYTHAT IN THE PERFUJIMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' C ST LIRE IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 442OS14SS.If423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> 6lprted X Tftl.& J ��fJVY/ - -' aS°...t�� Q� <br /> PLOT PLAN(Draw to Scalel Scab 'to <br /> 1. NAMES OF STREETS OR <br /> ROADS <br /> HEARS R 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 6. 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 /> DEPARTMENT USE ONLY <br /> AppFicetion Aooapted BY�- Date Arm <br /> Gran[Inspection BY Date? Pump Impection By .Date <br /> DeetruMion Uspaetlen BY One <br /> ol <br /> CornmenG: <br /> b� <br /> ACCOUNTING ONLY: AID* FAC* <br /> PE CODES FEE INFO AMOUNT RIPAITTED CHECK*ICASH RECEIVED PY DATE PEWFTr'&EFMCE REQUEST NUMBBI INVOICE <br /> o 6 s' - 0 !(v <br /> 4 <br />