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�. APPLICATION FOR WELLIPUMP PERMIT <br /> ,3 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> qL� ENVIRONMENTAL HEALTH DIVISION <br /> SQ. P 0 BOX 39R, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96�U �� <br /> {� (209)209) 464693420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> IComplets in Triplicate) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANO/OR INSTALL THE WOR(DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.�'Cr1�HAP/UR 9-1115.3 APP^THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADORESSMR AM, J J/./��I/ /•/I/ CITY N I W1 PARCEL SIZE/AM# -1 (�'1 <br /> OWNER'S NAME ) •_I I Nr/E--� / V" ADDRESS p o •, [n[ y —//� r✓ S� c�-"( PHONE R 1 O L <br /> CONTRACTORCIAMI VE-` •1 k ADDRESS 202.7 [' F ((,01`/// LIC# II J lf PHONEI Z <br /> SUB CONTRACTOR ADDRESS LICA PHONE# <br /> TYPE OF WELVPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL* J <br /> ❑New❑RepeR H.P. DEPTH PUMP SETFT. FIRST WATER LEVEL O <br /> V YPE OF PUMPI <br /> I/ /❑ OUT-0F(-/Sr)EIR1VIC/IE WELL ❑ GED YSICALWELL♦ ❑ SOIL BORING B <br /> ❑DESTRUCTION: I C� A L7' L�,J <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPEC CATIONS A <br /> ❑ INDUSTRIAL 11 OPEN BOTTOM DIA.OF CONDUCTOR CASING <br /> O <br /> ❑ DOMESTIC/PFIIVATE ❑GRAVEL PACK/SIZE DIA.OF WELL CASING D <br /> ❑ PUBLICMUNICIPAL ❑DRIVEN Lam_/—/ SPECIFICATION R <br /> ❑ IRRIGATION/AG ❑OTHER (fes / GROUT BRAND NAME E <br /> ❑ MONITORING ✓ // CONCRETE PEDESTAL BV DRILLER:❑Vs ON. 5 <br /> APPRO%.DEPTH B / // PE 5 <br /> PROPOSED CONSTRUCTION/DRWNO METHOD: MUD ROTARY_ _CABLE OTHER <br /> I HERERY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND TH ATH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES ANO <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICE )WING:•I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO W...--e acvMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBLOMRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IB ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.- THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REGURED INSPECTIONS AT 12M)40111J423. COMPLETE DRAWING AT LOWER AREA RW VIDED. <br /> SlEned % Title Date r, <br /> PLOT PLAN (Drew to Scale)Seals to 1, <br /> 1. 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. (/•t <br /> 3. DIMENSIONED OUTLINFS AND LOCATION OF ALL EXISTING AND PROPOSED 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,ONVEWAYS,AND WAIAS. ON THE PROPERTY OR ADJOINING PROPERTY. 1 <br /> Air 6 Ap &0 <br /> TA 14J l(_ wit <br /> 2-ria��iic <br /> �� 1 OrAIN�U� <br /> PAYMENT <br /> RECEIVED <br /> MAR 995 <br /> SAN JOA LAIN COUNTY <br /> RyIr <br /> PUBLIC HE lTH t'rrsV1�1 s .l <br /> L ENVIRONMENTAL HEAIJ H UIV ton I <br /> �p�� /p DEPARTMENT USE ONLY <br /> Application Accepted By c to Il— r.,r e' - �� _ at. I �I I AreaIF <br /> Glom IMpectlOp Byy Date Pump Inspection By Date <br /> Dmtrmtion Impmtlon By Data <br /> Comments <br /> ACCOUNTING ONLY: AID# FAC* <br /> PE CODES FEE INFO AMOUNT R TIED CHEC /CASH RECEIVED BY DATE PERMIT/SERACE REQUEST NUMBER INVOICE <br /> 3 ss < Uu <br />