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APPLICATION FOR WELLIPUMP PERMIT <br /> ("'\;AN JOAQUIN COUNTY PUBLIC HEALTH SERVI[7 <br /> ENVIRONMENTAL HEALTH DIVISION <br />` P 0 BOX 388, 446 N. SAN JOAQUIN ST, STOCKTON, CA 96201-388 <br /> (209) 488.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triprmta) <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. <br /> Job Address/or APN# O 7 W• -M Loo city _ L � t�� Parcel Size/APNIt �y <br /> Owner's Name L?�,$2 i 'rG�, -- Address/ol7 UA 1.11 AM—E4 -L t Phone #, e -// �t-cj <br /> j <br /> Contractor bC4,I f� IoL/is:. y2 E'er -- Address G �� � L Lic#/�-�373 - Phone #',4(6 <br /> Sub Contractor Address Lic# Phone # <br /> F6 TYPE OF WELL/PUMP: II NEW WELL 0 REPLACEMENT WELL [I MONITORING WELL # [1 OTHER <br /> [I DESTRUCTION i7 OUT-OF-SERVICE WELL [I GEOPHYSICAL WELL # II SOIL BORING <br /> INSTALLATION [I WELL SYSTEM REPAIR (I CROSS-CONNECT REPAIR [I VAPOR EXTRACTION WELL # <br /> [I New Il Repair H.P. DEPTH PL94P SET f O46— FT. FIRST HATER LEVEL Gvg <br /> F (TYPE OF PUMP) <br /> . INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> [I INDUSTRIAL II OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING <br /> (I DOMESTIC/PRIVATE [I GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA. OF WELL CASING <br /> [I PUBLIC/MUNICIPAL [I DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> Q <br /> [IIRRIGATION/AG [I OTHER GROUT, SEAL INSTALLED BY GROUT BRAND NAME <br /> [I MONITORING GROUT SEAL PUMPED: ❑ Yes [I No CONCRETE PEDESTAL BY DRILLER: [I Yes [I No <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTRUCTIONIDRILLING METHOD: 14UD 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, <br /> State Laws, and Rules and Regulations of the San Joaquin County. Home owner or licensed agent's signature certifies the following: "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 Catifornia." Contractor's hiring or sub-contracting signature certifies the following: 11 1 certify that in the performance <br /> of th4 work for which this permit is issued, I shall employ persons subject to WORKMAN'S COMPENSATION Laws of California." THE APPLICANT <br /> I MUST CAI'24 HO IN ADVANCE FOR All REQUIRED INSPECTIONS AT{2Dli 4B8.342d. Gaapiet�el�drawing at Lower area provided. f i �r�F <br /> + Signed X ))1,�tleqcf _ Date ' , '7 <br /> PLOT PLAN (Draw to Scale) Scate " to <br /> 1. Names of streets or roads nearest to or bounding the property. 4. Location of house sewage disposal system or <br /> 2. Outline of thePe Yro rt . giving dimensions and North direction. proposed expansion of sewage disposal systems. <br /> P <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 walks. <br /> f <br /> i <br /> I <br /> r? 4A p <br /> 1 <br /> C � <br /> IJCRCiV <br /> 4 9,SAAQ II! " Ou; i CELt L�l <br />