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r <br /> v N JOAOWN COUNTY PUBLIC HEALTH SERVICE <br /> APPLICATION FOR W_ELLIPUMP PERMIT I <br /> ENVIRONMENTAL HEALTH DIVISION II <br /> P 0 BOX 388, 446 N. SAN JOAOUIN ST., STOCKTON, CA 96201-388 <br /> (209).468-342.0 <br /> µNON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Tripliemtm) <br /> Application is here by made to the San Joaquin County for a permit to construct and/or install the work described. This' apptication.is <br /> made in compliance with San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br /> Services, Environmental Health Division. <br /> Job Address/or APN# (05-V 50"±6 U I { City Parcel Size/APN# - <br /> Owner's Name1 Address -', Phone # " <br /> Contractor AddressZftX 02 /hydeA L) G.J Lic# Phone <br /> Sub Contractor 1��rTriv[���`�i2►Jf.n1- Address � : cx3 Lic9 4-1� Pho�q#�� <br /> '6 1 <br /> TYPE OF WELL/PUMP: II NEW WELL ❑ REPLACEMENT WELL [I MONITORING WELL # [I OTHER <br /> I] DESTRUCTION [I OUT-OF-SERVICE WELL [I GEOPHYSICAL WELL # ❑ SOIL BORING f <br /> (] INSTALLATION [I WELL SYSTEM REPAIR [I CROSSCONNECT REPAIR VAPOR EXTRACTION WELL #&-10 <br /> (I New ❑ Repair H.P. DEPTH PUMP SET FT. °r FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> p <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> [I INDUSTRIAL (I OPEN BOTTOM DIA. OF WELL EXCAVATION �� DIA. OF;CONDUCTOR CASING M. <br /> I] DOMESTIC/PRIVATE (] GRAVEL PACK/SIZE TYPE OF CASING/STEEL DIA. OF{WELL CASING <br /> [I PUBLIC/MUNICIPAL [] DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> [I IRRIGATION/AG [I OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAMECSe� <br /> MONITORING GROUT SEAL PUMPED: 0 Yes [I No CONCRETE PEDESTAL BY DRILLER: [I Yes 11!!No <br /> APPROX.DEPTH r LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTRUCTIONJDRILLING METHOD: MUD ROTARY AIR ROTARY_ AUGER CABLE_ OTHER y I <br /> I <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, 3 <br /> State Laws, and Rules and Regulations of the San Joaquin County. Home owner or licensed agent's signature certifies the.following:!k"I 1 <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 WORKMAN'S COMPENSATION Laws of California." THEAPPLICANT <br /> MUST CALL 24 HOURS IN ADVANCE FOR ALL REGUIRED INSPECTIONS AT 1208)468.3423. Complete drawing at lower area provided. <br /> Signed X tl7 _ Title Date -� <br /> PLOT PLAN (Draw to scale) Scale "-to <br /> 1. Hames of streets or roads nearest to or bounding the property. 4. Location of house sewage disposat system or <br /> 2. Outline of the property, giving dimensions and North direction. proposed expansion of sewage disposat systems. <br /> 3. Dimensioned outlines and location of all. 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 watks. p <br /> 'I <br /> I, <br /> ;r <br /> DEPARTMENT USE ONLY h <br /> Application Accepted By Date ^,". Area` r <br /> Grout Inspection BDate Pump Inspection By Date <br /> Destruction Inspection By Date Comments: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> t <br /> t <br />