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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVI..,l, <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOADUIN ST., STOCKTON, CA 96201388 <br /> (209) 4683420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete is Trplicata) <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/ n1' ,, <br /> /I^ I ��YMEr� � Li ty Parcel Size/APN# <br /> Job Address/or APNk --1 YMEL-1) �) <br /> Address 1 Phone #& <br /> Owner's Name pp /� <br /> Contractor � <br /> Address Pct f>OX �� I 1C Lic# Phone #TL/ <br /> Sub Contractor <br /> Address Lic# Phone # <br /> TYPE OF WELL/PUMP: [) NEW WELL [) REPLACEMENT WELL [) MONITORING WELL # [) OTHER <br /> ❑ DESTRUCTION [I OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL # [) SOIL BORING <br /> [I INSTALLATION %-40ELL SYSTEM REPAIR [I CROSS-CONNECT REPAIR [) VAPOR EXTRACTION [ #-,,o,. #_ <br /> () New ljYRepair H.P. DEPTH PUMP SET (e FT. FIRST WATER LEVEL <br /> (T PE PUMP) 'U <br /> INTENDED USE TYPE OF WEII CONSTRUCTION SPECIFICATIONS <br /> [) INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING n <br /> >rOOMESTIC/PRIVATE [] GRAVEL PACK/SIZE_ TYPE OF CASING/STEEL/PVC DIA. OF WELL CASING <br /> [) PUBLIC/MUNICIPAL [) DRIVEN DEPTH OF GRWT SEAL SPECIFICATION <br /> () IRRIGATION/AG [) OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> [) MONITORING GROUT SEAL PUMPED: [) Yes [) No CONCRETE PEDESTAL BY DRILLER: ❑ Yes [3 No <br /> APPROX. DEPTH LOCKING CHESTER BOX/STOVE PIPE C <br /> PROPOSED CONSTRUCTIONIORILLING 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 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: "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 2 OURS IMADVANCE FOR ALL REQUIRED INSPECTIONS AT (205)4583423. Comp Lete drawin a /^Lo,^we�^rarea provided. <br /> Signed X r � �/� �. Q Title O Da � <br /> PLOT PLAN (Draw to Scale) Scale " 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 property, giving dimensions and North direction. proposed expansion of sewage disposal systems. <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, riveways, the property or adjoining property, <br /> and walks. <br /> 1 < <br /> DE RTMENT E ONLY <br /> Application Accepted By Ditto P iz3pAre9 <br /> Grout Inspection By Date Pump Inspection BDate 11 ' <br /> Destruction Inspection By DateComments: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEF INFO AN19YNT REMITTEDEC CASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> L4 q e4 cl 0lso30 <br />