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APPLICATION FOR WELLIPUMP PERMIT I <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> + ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201-388 <br /> 12091 488-3420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED U U <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. q��t ��7 �1 <br /> Job Address/ort' // TZ Z q fDiY�61hj1 t/ `C�� City fq&f/NG7oN Parcel Size/APN# �V�i�- '+, <br /> Owner's Nam .f �DE OUSSt Address P9 8OX /229 CA Phone <br /> contrectorQSTE�$E P�Fs%�w4�T Address �'7`/l �!/E/Z D. )%/-t TAc# 3/3/6670 Phone # 537-5-767 <br /> Sub Contractor Address Lic# Phone # <br /> TYPE OF WELL/PUMP: n NEN WELL ❑ REPLACEMENT WELL [I MONITORING WELL # [) OTHER <br /> [1 DESTRUCTION ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL # ❑ SOIL BORING <br /> y[I INSTALLATION 11 WELL SYSTEM REPAIR [I CROSS-CONNECT REPAIR [I VAPOR EXTRACTION WELL # <br /> TUREIQe- YA New ❑ Repair H.P.7S DEPTH PUMP SET 190 FT. FIRST WATER LEVELY ZO <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ❑ INDUSTRIAL OPEN BOTTOM DIA. OF WELL EXCAVATION IS-IAF DIA. OF CONDUCTOR CASING-1 91' <br /> ❑ DOMESTIC/PRIVATE [I GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC STEEL DIA. OF WELL CASING <br /> (I PUBLIC/MUNICIPAL H DRIVEN DEPTH OF GROUT SEAL S O SPECIFICATION '/ <br /> X, IRRIGATION/AG [I OTHER GROUT SEAL INSTALLED BY DeICi.E2 GROUT BRAND NAME C-Ey ELL7 )gy7p(I <br /> [] MONITORING GROUT SEAL PUMPED: ' Yes (I No CONCRETE PEDESTAL BY DRILLER: ❑ Yes [1 No� <br /> APPROX. DEPTH 373 O LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTRUCTIONIDRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE X OTHER <br /> I hereby certify that I have prepared this application and that the work wilt 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: 111 C� <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: " 1 certify that in the performance <br /> of the w which this permits issued, I shall employ persons subject to WORKMAN'S COMPENSATION Laws of California." THEAPPLICAN� <br /> MUST C L 24 HO RS IN ADVANCE FO Ll REOUIREO INSPECTIONS AT 12011488,1423. Complete drawing at Lower,,are. <br /> provided. -{],� <br /> Signed % / Title L�?7Z^i<'(�C-�L Date J�14 <br /> Z. — <br /> PLOT PLAN (Draw to Scale) Scale 16 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 the pro rty, giving dimensions and North direction. proposed expansion of sewage disposal systems. <br /> 3. Dimensioned outlines and Location of alt 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 /> e � <br /> ih <br /> en <br /> (w <br /> b <br /> y <br /> K tdi - 1 4", P <br /> l i <br /> DEPARTMENT USE ONLY / 'z <br /> Application Accepted By -� Date b I J Area�_� <br /> Grout Inspection eyt� /' ��✓ /pate Pump Inspection By Date <br /> Destruction Inspection By_ - Date Comments: 2< Z� S `.S� <br /> ACCOUNTING ONLY: p AID# FAC# <br /> PE CODES FE//AFII AMOUNT REMITTED HEC CASH RECEIVED BY DATE PERMITISERVICE REOUEST NUMBER INVOICE <br /> 03a&8,2- <br /> 0301083 <br />