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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAO=COUNTY PUBLIC HEALTH SERVICES <br /> `f ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388,446 N.SAN JOADUIN ST,STOCKTON,CA 96201.389"' <br /> (209)488.3420 <br /> NONREFUNDABLE PERMIT EXPIRE$I YEAR FROM DATE ISSUED <br /> _ H'.a"Ists Is T►*Nsats) <br /> r <br /> Application <br /> intcoapliance with S n Josquin Countto the son tD velopmentin County or a Title, Chapter ensit to construct <br /> 1115 3 and the Standards f on Jcoaqubin County PPubliction Is <br /> Health <br /> Services, Environmental. Health Division. <br /> Job Address/or APN# 3$0* Gv2ON1OG city ST3ckT1]N Parcel Size/APN# <br /> .s 9&—S74 <br /> Cc <br /> owners Name Sf a%9T- CoAA0 10411�-)CO-Address 901 e-W— (O4�ST )CA kSGiY,JlO Phone s -s 3 <br /> 610610Contractor ?-Vt-70ft 1T[bPACIs A--- Address 4t3e�0 LftOio QICN► Lief Phone IF J12-3a'ID <br /> Sub Contractor S( Z�77sJNU et�V-bettUWQAddress2f{L�YLYIL1C SMO- LICSCV Z(o[? Phone MT%S Z <br /> ..r <br /> TYPE OF HELI/PUMP: [] NEN WELL [] REPLACEMENT WELL 0 MONITORING WELL # [] OTHER S-�KIrO 1 <br /> [] DESTRUCTION I] OUT-OF-SERVICE WELL U GEOPHYSICAL WELL # J*SOIL BORING <br /> [] INSTALLATION [] WELL SYSTEM REPAIR [1 CROSS-CONNECT REPAIR U VAPOR EXTRACTION WELL # <br /> ..r <br /> 11 New [1 Repair M.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> [1 INDUSTRIAL [] OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING <br /> 11 DOMESTIC/PRIVATE U GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA. OF WELL CASING <br /> D PUBLIC/IAIMICIPAL 0 DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> [] IRRIGATION/AG [1 OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> U MONITORING GROUT SEAL PUMPED: D Yes U No CONCRETE PEDESTAL BY DRILLER: 11 Yes 11 No <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTRUCTIONIORILLING METHOD: MUD ROTARY_AIR ROTARY_AUGER_CABLE_OTHER_ <br /> ..r I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, <br /> State Laws, and Rules and Regulations of the San Josqutn County. Name owner or licensed agent's ollowing: -1 <br /> subject toifWORKMAN'S ies the (COMPENSATION <br /> certify that in the performance of the work for which this permit is issued, I shall not employ persons <br /> Laws of California." Contractors hiring or subcontracting signature certifies the following: " t certify that in the performance <br /> of the work for which this permit is issued, 1 shall employ persons subject to WORKMAN'S COMPENSATION Laws of California." THE APPLICANT <br /> ^, MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION$AT(201)486.2423. Complete drawing at lower area provided. <br /> iy Title Rte- �EZ.wCil�r Date9-Z}�/► <br /> Signed X <br /> PLOT PLAN (Draw to Scale) Scale ( " to 101 <br /> 1. Names of streets or roads nearest to or bounding the property. 4. Location of house sewage disposal system or <br /> giving dimensions and North direction. proposed expansion of sewage disposal systems. <br /> 2. Outline of the property, g Location of wells within radius of 150 ft. on <br /> 3. Dimensioned outlines and location of ell existing and proposed 5. the property or adjoining property. <br /> structures, including covered areas such as patios, driveways, P Pe Y <br /> end walks. 1 <br /> -- __ 3 619 <br /> LZlly�� <br /> NVIRONMENTAL SERVICES, INC. <br /> PH.510-222-7810 <br /> 4138 LAKESIDE DR. I 11-24 <br /> RICHMOND,CA 94802 19_!A <br /> 9! il- 12188) <br /> -i �`�� J V 1C� <br /> ..+ T`Y—N\N� DOLLARS <br /> EL CERRITO PLAZA OFFICEELLS FARGO BANKOD SAN PABLO AVENUE.EL CERRITO.CA 94370 j'ee,'S - --- ------- --------- <br /> FOR11000 36 L9115 1: 12 1000 2481:0 13 L 0 L S 588118 <br /> DEPARTMENT USE USE ONLY <br /> Application Accepted By - DateArea <br /> Grout Inspection eDate PUT Inspection 8y Date <br /> y <br /> Destruction Inspection By Date Comments: <br /> k, kuk <br /> �.+ ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK ASH RFyV.ED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> nn <br />