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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION �.� <br /> P O BOX 388,446 N.SAN JOAQUIN ST,STOCKTON.CA 96201.39 <br /> (209)468.3420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplintel <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 <br /> made in compliance with San Joaquin Canty Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br /> Services, Environmental Health Division. <br /> Job Address/or APMN 35(2- Ca¢.e14ko0 AV1 Cie S'R+�kIDN <br /> Y Parcel Stze/APNM <br /> Owner's Name SOMIJr C0AA0WK4-1�CO-Address 901 t—W 10+Ta ICMMS)SGL1Y A0 Phone r%—S,X43 <br /> Contractor �1t-OFL El.>``l9b J14CW1*t, Address 4klf LAVES(Of 12,t4Ad1A <br /> LieNPhone#qty - 16 <br /> sub Contractor S(1eMIRtJf4 EtW-1`e((U/<TAddress2'ersj LytzTLr $'mlb- LicAC&5-TZZ(.9 Phone 0%5-8:31 2 <br /> TYPE OF YELL/PUMP: 11 NEW WELL t] REPLACEMENT WELL (1 MONITORING WELL N [1 OTHER <br /> (1 DESTRUCTION U OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL # j*SOIL BORING S BCKINO� <br /> 0 INSTALLATION U WELL SYSTEM REPAIR U CROSSCONNECT REPAIR t] VAPOR EXTRACTION WELL N <br /> U New [3 Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> [] INDUSTRIAL (1 OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING <br /> (1 DOMESTIC/PRIVATE [1 GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA. OF WELL CASING <br /> (1 PUBLIC/MUNICIPAL 11 DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> (1 IRRIGATION/AG (1 OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> U MONITORING GROUT SEAL PUMPED: U Yes 0 No CONCRETE PEDESTAL BY DRILLER: U Yes U No <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTRUCTIOMIORILLING METHOD: !U1 ROTARY_AIR ROTARY_AUGER_CABLE_OTHER_ <br /> I hereby certify that I have prepared this application end that the work will be done in accordance with San Joaquin County Ordinances, <br /> State Laws, and Rules and Regulations of the San Josquin County. Now owner or licensed agent's signature certifies the following: "I <br /> certify that in the performance of the work for which this permit is issued, I shall not employ persons subject to WORKMAN'S COMPENSATION <br /> Laws of California." Contractor's hiring or sub-contracting signature certifies the following: " I certify that in the performance <br /> of the work for which this permit is issued, I shall employ persons subject to WORKMAM'S COMPENSATION Laws of California." TREAPPUCANT <br /> MUST CALL 24 HOURS IN ADVANCE FDN ALL REVINNED INSPECTIONS AT(2081488.3423. Complete drawing at lower area provided. <br /> Signed X �' �'�"'�'� Title RtZi- CEZJ-C)GtSX Oate9-7}-44 <br /> PLOT PLAN (Draw to Scale) Seale 1 " to Za, <br /> 1. Names of streets or roads nearest !o or bonding the property. 4. Location of house sewage disposal system or <br /> 2. Outline of the property, giving diversions and North direction. proposed expansion of sewage disposal systems. <br /> 3. Dimensioned outlines and location of ail existing and proposed 5. Location of wells within radius of 150 ft, on <br /> structures, including covered areas such as patios, driveways, the property or adjoining property. <br /> and walks. <br /> DEPARTMENT USE ONLY <br /> Application Accepted ey Date Area <br /> Grout Inspection By Date Pump Inspection By Date <br /> Destruction Inspection By Date Comments: <br /> Issue, �,G1(a� <br /> ACCOUNTING ONLY. AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK ASH REWED BY DATE PERMITISERViCE REQUEST NUMBER INVOICE <br /> .ate -2 S <br />