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APPLICATION FOR WELLIPUMP PERMIT 001 ze9z . <br /> aAN JOAOUIN COUNTY PUBLIC HEALTH SERVh, <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 388, 446 N. SAN JOAOUIN ST.. STOCKTON, CA 85201.388 C (Dpy� <br /> (209) 468-3420 <br /> NOW-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM RATE ISSUED <br /> (Complete In TFiplioat§l <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 MADE IN COMPLIANCEWITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8.11'15.3 AND THE ANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. c <br /> JOB ADDRESSOR APN# , CITY U y� <br /> i'd PARCEL SIZE/APNI <br />'4 OWNER'S NAME • ADDRESS w.� <br /> PHONE M <br /> CONTRACTOR GL.C./ ADDRESS LICA► PHONE# <br /> SUB CONTRACTOR ADDRESS <br /> LIC# PHONE# <br /> TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER 3 <br /> ❑ INSTALLATION ❑ WELL STEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# JI <br /> ❑Now Rapalr H.P. DEPTH PUMP SETFT. FIRST WATER LEVEL <br /> (TYPE OF PUMP} - O <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL SORING 8 <br /> ❑DESTRUCTION: � <br /> r : <br /> INTErlDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A C <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING p <br /> DOMESTIC/PRIVATE T GRAVEL PACK/SIZE <br /> TYPE OF CA81NG1STEELIPI7C DIA.OF WELL CASINO p ' <br /> © PUBUC/MUNICiPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION :tom. <br /> ❑ IRRIGATION/AG ❑OTHER R <br /> GROUT SEAL INSTALLED BY GROUT BRAND NAME F O <br /> ❑ MONITORING ! GROUT SEAL PUMPED; ❑YM ❑No CONCRETE PEDESTAL BY DRILLER:❑Yas ON. S- <br /> APPROX.DEPTH LOCKING CHESTER BOXISTOVE PIPE S, <br /> PROPOSED CONSTRUCTIONIDRILLiNG 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 VNTH BAN 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:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT 70 WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUS-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING; 'I CERTIFY THAT IN TME P RM E OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'&COMPENSATION LAWS OF <br /> CALIFORNI AP CANT MUST CA ADVANCE FOR ALL REQUIRED INSPECTION&AT 12091408-3422. COMPLETE DRAWING AT LOWER AREA PROVID D. <br /> Signed X Title l` 0110$g _ _ Da - <br /> PLOT PLAN}Draw to Scala)Scale "to <br /> t, NAMES OF STREETS OR ROADS NEAREST TO OR 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 S. 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 /> i.. - .... .. - _ f <br /> :.. <br /> . <br /> b 5 <br /> : <br /> .... ... . .. ...... ,'°.. . <br /> ,.. .. <br /> ... ...... . ....;... .;. <br /> . . <br /> ... ..... ....:.. .. .. . <br /> .. <br /> . ... . . . ..... <br /> :.....:.... <br /> J <br /> U.N s �g <br /> ... .... . <br /> r L) . <br /> AL <br /> � 4IlC� <br /> �hlVff��,NM <br /> N D1Ud51C'N.. <br /> �c-DEPARTflIIENT U&E ON LY <br /> Application Accepted By Data Area ' <br /> 61 <br /> Grout Inspection By Date Pump Inspection By pate <br /> Destruction Inspection By Data 'e <br /> Comments: I <br /> e <br /> t <br /> EN <br /> ACCOUNTING ONLY. AID# FAC# <br /> PECODES FEE INFO AMOUNT REMITTED CHEC ASH RECEIVED BY DATE PERMtTISOMCE REQUEST NUMBER INVOICE <br /> 7 76s <br />