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APPLICATION FOR WELUPUMP PERMIT <br /> ie,,iAN JOAQUIN COUNTY PUBLIC HEALTH SERVIL <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 446 N. SAN JOADUIN ST., STOCKTON, CA 96201-388 <br /> (209) 46&3420 <br /> NOW PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <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 County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br /> Services, Environmental Health Division. 1 /[� �I A I <br /> Job Address/or APN#J 0 ! 99' S I4/ 14 Jl PO <br /> �City Ict Svc C,4 Parcel Size/APN# <br /> Owner's Name !.3 eN/e T"0 I moi- C ../ Address /_O I"O`'/' �/J'/�r ^wFSi .SACS'' �� Ph ne # 3 <br /> Contractor C(41 K LAIELC/ TNf Address 2027 F 04177! Lic# 37/SPhone # y —7 <br /> Sub Contractor Address Lic# Phone # <br /> TYPE OF WELL/PUMP: [I NEW WELL (I REPLACEMENT WELL [I MONITORING WELL # [I OTHER <br /> t;,4'ESTRUCTION (I OUT-OF-SERVICE WELL [I GEOPHYSICAL WELL # [I SOIL BORING <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WILL # <br /> [I New [I Repair H.P. / ,,II DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) PVC P l P E- - IZI LL (3 0 Tre" T f av P - 4 SACC s,o,(r oAl <br /> ?�Cl�l r <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Q INDUSTRIAL (I OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING <br /> [) DOMESTIC/PRIVATE ❑ GRAVEL PACK/SIZE_ TYPE OF CASING/STEEL/PVC DIA. OF WELL CASING <br /> [I PUBLIC/MUNICIPAL [I DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> ❑ IRRIGATION/AG ❑ OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> [I MONITORING (� GROUT SEAL PUMPED: [I Yes [I No CONCRETE PEDESTAL BY DRILLER: (IYes [I No <br /> 1A`1 <br /> APPROX. DEPTH r / LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTRUCTIONIDRILLING METHOD: MUD ROTARY_ AIR ROTARY_ AUGER_ CABLE_ OTHER_ C <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, C <br /> State Laws, and Rules and Regulations of the San Joaquin County. Home 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 WORKMAN'S COMPENSATION Laws of California." THEAPPLICANT <br /> MUST CALL 24 NO RS IN ADD C /IA REOUIRED INSPECTIONS AT 12091488-3423. Complete drawing ,at ower area provided. <br /> prrrovided. A/d y J <br /> Signed X / /[ ( /p(�l/'� _ . _ Title 1 — Ct4 Pl(V Da _./y <br /> PLOT PLAN (Draw to Scaler w�yyto <br /> 1. Names of streets or roads nearest to or bounding the propert („r (y�1E�4. Location of house sewage disposal system or <br /> Us- <br /> 2. Outline of the property, gi ng dimensions and North directi C, 61994 proposed expansion of sewage disposal systems. <br /> 3. Dimensioned outlines and loca 'on of a[( existing and propos � i� Location of wells within radius of 150 ft. on <br /> structures, including cover reqs such as patios, driv pkJQAQU IN COU N 1Y She property or adjoining property. <br /> and walks. \ PUBLIC HE.ALTM SERVICES <br /> �j DEPARTMENT USE ONLY <br /> Application Accepted By _. (_l� T�-�-� _ Date Area�✓� <br /> Grout Inspection By Date Pump Inspection By / Date <br /> Destruction Inspection By Datef!44,45�'CommenLs: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTEDCHECK CASH RECEI:EO BY DATE PERMITISERVICE REOUEST NUMBER INVOICE <br /> ) { 3 (0 0 GD• xylly G 5 <br />