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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SER. 4S <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 386, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br /> (209) 4883420 <br /> NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete In Ttiplleete) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAP <br /> JOAQUIN COUNTTYYDEVELOP ENT TITLE,CHAPTER 8-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HpALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESS/ON�O CIT[V/✓'���/ <br /> � PARCEL SIZE/APN/ <br /> ADDESS ` *j;Q U-11T PHONE ,23 <br /> L(�v Sq/,94OWNER'{NAME <br /> CONTRACTOR p ADDMSSjqeA/&.-f / /o <br /> PHONE <br /> BUB CONTRACTOR ADDRESS UCI PHONE <br /> ��II--�A ♦ <br /> TYPE OF WELLIPUMP: PYLNEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL 0 ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL 0� J <br /> TYPE OF PUMP/ H.P.— DEPTH PUMP SET—FT. ITTT ILLEVEL <br /> ❑N.w❑Rrlir ❑ OUT-OFSERVICE WELL ❑ GEOPHYSICAL WELL I L, ILrSORINO � /.P7© (.CI B <br /> ( ,j <br /> 11 DESTRUCTION: go SC1LtAL& <br /> INTENDED USE TYPE Of WELL CONSTRUCTION SPECIFICATION{ A <br /> ❑ INDUSTRIAL ��❑ryryOP�EN BOTTOM DIA.OF WELL EXCAVATION A DIA.OF CONDUCTOR CASING DI <br /> WMESTICMRIVATE LpELHRAVEL PACKISIZE TYPE OF CASING/STEEL C PL16 DIA.OF WELL CASING A <br /> ,n O <br /> ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY 1'1114,C—'111j GROUT BRAND NAME E <br /> C3 MONITORING q I GROUT SEAL PI/MPEDURYr [IN. CONCRETE PEDESTAL 5 <br /> APPROX.DEPTH /�y1�J lV( LOCKING CHESTER BOX/STOVE PIPE 5. <br /> PROPOSED CONSTRUCCTIONIMYWNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:9 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH <br /> THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'{COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: •1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,I SHALL EMPLOY PERSONS SVWECT TO WORKMAN'{COMPENSATION"WOOF <br /> CALIFORNIA.• THE APPLICANT MUST C//ALLLJ 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPSGTIO AT 120e14pS42{. COMPLETE DRAWING AT LOWER AREA PR//b'')V)IpED"".��)��� !!,.,� <br /> 61PtidX �L_� TIB. � r(r���0 D.I./O—G54 '& <br /> PLOT PLAN Draw to Se.NI Sul. •to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> Z. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT, <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WAL(S. /J ON THE PROPERTY OR ADJOINING PROPERTY. <br /> 4 <br /> . fie H L .... .... <br /> c ` <br /> CSI <br /> I <br /> om <br /> DE►MTMFJVT USE ONLY <br /> Applle.tlen Aormtetl By 1/n11 ���'l!f � q Q I D.l.// / / ^' Ars. �/YJ • �' <br /> Grow Irr.PrNon Br ` 0� D.I. F2-1 )- •Pu P IMPWI*rI By <br /> 'l q e D.t. <br /> prlr.enon I�.P//.=--o-�en By/I 0&- efts /'1-a,r0 .L ' �D".I. <br /> commenlr: (IG04ea ;C. I byyj ILr:) OA . YV� Qi!'1�111r Gwn Sapwlycil�la <br /> o✓t :LRA WJUII-L . •0 Gt'ed--t v l 11e '� 1,AJ64 �✓Vki e✓ <br /> ACCOUNTING ONLY: AID/ FACI <br /> PE COD" FEE INFO AMOUNT REMITTED CHECK//CASH RECEVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> No I W . OV s12 0 7`15o3a 8 <br /> `� 50 5o • 00 (pI SR— VI'D 79 (v 03a8�1 <br />