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w- APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIC. <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOADUIN ST., STOCKTON, CA 95201.388 <br /> (209) 489.3420 <br /> NON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> IComplata 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. /J s 'A4 <br /> Job Address/orAPN# '� Ste( A/ AkCity � �h�S _ Parcel Size/APN# <br /> Owner's Name 4 r L&/� r 7T Address r 77 IE Phone # <br /> Contracto I v4G IZO <br /> nS Address 0 Lic# —S Phone y �- <br /> Sub Contractor � Address Lic# Phone # <br /> TYPE OF WELL PUMP: ,0 NEW WELL [I REPLACEMENT WELL [] MONITORING WELL # [] OTHER <br /> [] DESTRUCTION [] OUT-OF-SERVICE WELL [] GEOPHYSICAL WELL # [] SOIL BORING <br /> ' INSTALLATION [] WELL SYSTEM REPAIR [] CROSS-CONNECT REPAIR [I VAPOR EXTRACTION WELL # <br /> p(New [] Repair H.P. _ _ DEPTH PUMP SET I UA _FT. FIRST WATER LEVEL 1 <br /> (TYPE OF PUMP) <br /> r <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> b INDUSTRIAL [] OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING <br /> DOMESTIC/PRIVATE X GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC r�C- DLA. OF WELL CASING C <br /> [] PUBLIC/MUNICIPAL [I DRIVEN DEPTH OF GROUT SEAL SPECIFICATION F! A C <br /> [I IRRIGATION/AG [] OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> � <br /> [] MONITORING GROUT SEAL PUMPED:, Yes [I No CONCRETE PEDESTAL BY DRILLER: Yes [] Noz t <br /> �. I <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CO NST RUCTIONIORILLING 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: 111!� <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 C <br /> Laws of California," Contractor's hiring or sub-contracting signature certifies the following: "'1 certify that in the performance 7 <br /> of the work for which this permit is issued, I shall employ persons subject to WORKMAN'S COMPENSATION Laws of California." THE APPLICANT <br /> MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT(20114118-3423. Complete drawing at lower area provided. <br /> Signed Title W D ted—�7—� <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, driveways, the property or adjoining property. <br /> and walks. <br /> V <br /> T <br /> D. <br /> 1. 5 <br /> AF pA �� C Y <br /> ;gyp L BL - EAS H'D U15k N <br /> DEPARTMENT USE ONLY <br /> Application.Accepted By DatArea��— <br /> Grout Inspection By Date %'pump Inspection By Date <br /> Destruction Inspection 8y Date Comments: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED ECL( ASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> 43 to <br /> g a D g <br />