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APPLICATlON`FOR'WELLIPUMP <br /> AN JOAQUIN COUNTY PUBLIC HEALTH SEA' <br /> ENVIRONMENTAL HEALTH DI • - <br /> P.O. BOX vrsroN <br /> 988, 904 EAST WEBER AVENUE S N" <br /> tA <br /> (209) 468.3420 ; 9 ` f <br /> A <br /> NON-REFUNDABLE PERMIT EXPIRES <br /> APPLICA710N f YEAR FROM DATE ISS <br /> UED <br /> fCBmpMtE In TrrPBcah1 <br /> IS HERE By MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TR CONSTRUCT AND/OR INSTALL T <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 8-1 115.3 AND THE STANDARDS OF SAN JDA / + <br /> OUIk COUNTY PUBLICLTII SERVICES,HENVIRONIS IMENTAL HEgLDH DIVISION. <br /> ANCE WITH BAN <br /> JOB AbDAE88roR AF N# INC 1 +� <br /> S + CITY 5�T � <br /> OWNER'S NAME D PARCEL SIZE Dye <br /> _ - <br /> ADDRESS � 0/NE N <br /> CONTRACTOR <br /> ADDRESS `,l�D F OA�IOL }�3. <br /> SU8 CONTRACTOR r-'1L ) ® PHGNE R <br /> .. ADbR£BS �� LIC# PHONE#3742411 <br /> TYPE OF WELIJPUMP: ❑ NEW IVILL ❑ REPLACEMENT WELL ❑ MONITORING WELL# <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ OTHER <br /> ❑ CR08S-CONNECT REPAIR 11 VAPOR EXTRACT{ON W�# <br /> (3 NOW❑Repelr H.P. a J <br /> (TYPE OF pUMPj � DEPTH PUMP SET FT, FIRST WATER LEVEL I <br /> ❑ OUT-OF-SERVICE WELL ❑ QEOPHYSICAL WELL# ! ❑ SOIL$ORING <br /> INTENDED USE TYPE OF WELL <br /> + CONSTRUCTION SPECIFICATIONS <br /> ( ❑ INDUSTRIAL ❑OPEN BOTTOMSII <br /> A <br /> DIA.OF WELL EXCAVATION DIA,OF CONDUCTOR CASING A <br /> ❑ DOMESTIC/PRIVATE ,t <br /> ❑GRAVEL PACK/SIZE TYPE OF CAS4NOlBTEELl4'VC DIA,OF WELL CASING -' D <br /> ❑ PUBLiClMUNFCIPAL 11 DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY <br /> I GROUT BRAND NAME E <br /> ❑ MONITORING GROUT SEAL PUMPED: ❑Yee ©No CONCRETE PEDESTAL BY DRILLER:❑Yee ❑No S <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIP£ S i <br /> I <br /> i PROPOSED CONSTRUCTIONIDAILIJNG 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,SLATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FO&OWING:-1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT 18 ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIIF1E9 <br /> THE FO LLO NG: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMtT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> 401CAUrORNM. THE CA T MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12MI 4SCOMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Signed X TitleDote .116 <br /> Of 1/ f <br /> : . ...... ... .. ga . <br /> i 1 <br /> I <br /> �... .. . . <br /> - ..... .. ---y - <br /> ' DEPARTMENT USE ONLY F <br /> Application Aaaapted By Date� <br /> Grout Inspection By Date Pump Irupectlon By pits <br /> Destruction Inspection By Dote altnMr <br /> Comments: Z <br /> �1 <br /> i <br /> ACCOUNTING ONLY: AID# - FACE <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVEDAy DATE ',F PERMITISERVICE REQUEST NUMBER INVOICE <br /> 7i v <br /> V _ _ <br />