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APPLICATION FOR WELLIPUNIP PERMIT -- --- --- <br /> N JOAQUIN COUNTY PUBLIC HEALTH SERVICE; R <br /> ENVIRONMENTAL HEALTH DIVISION ~ <br /> P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201.398 <br /> (2091 498-3420 <br /> MON•REFUNOADLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> iComplets in Tripliaatel <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#-- j5t 1 city C-Q Parcel Size/APN# <br /> Owner's Name Address Phone # <br /> 6 U4 <br /> ContractoraO� Addressl`U Lic# Phoma # Cj <br /> Sub Contractor Address Lic# # { <br /> TYPE OF WELL PUMP: ❑ NEW WELL [I REPLACEMENT WELL 11 MONITORING WELL # U OTHER <br /> [) DESTRUCTION [I OUT-OF-SERVICE WELL [I GEOPHYSICAL WELL # [I SOIL BORING <br /> rYINSTALLAT-ION [I WEL SYSTEM REPAIR [I CROSS-CONNECT EPAIR 11 VAPOR EXTRACTION L-# <br /> S&I)Dlaw [] Repair H•.P ` DEPTH PUMP SET_ FT. FIRST WATER LEVEL <br /> E 0 PUMP) _" <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS J <br /> Q INDUSTRIAL [I OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING <br /> C W_ OMEST_ICLPRIVATE [j GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA. OF WELL CASING <br /> [I PUBLIC/MUNICIPAL [I DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> [I IRRIGATION/AG U OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> [I MONITORING GROUT SEAL PUMPED: Q Yes [I No CONCRETE PEDESTAL BY DRILLER: [I Yes U No <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTRUCTIONIORILLIHG METHOD: MUD ROTARY_ AIR ROTARY_ AUGER_ CABLE_ OTHER_ <br /> to <br /> O <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, J <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 shalt 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 work for which this permit is issued, I shall employ persons subject to WORKMAN'S COMPENSATION Laws of California." THE APPLICANT <br /> MUST CALL 2 OURS IN AOVA ORAL REQUIRED INSPECTIONS AT 1201)488.3423. complete djawing at tower area provided. rx� <br /> Signed X Title QA Do 10, ` <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 at( 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 /> kkkL <br /> INA. I <br /> S <br /> I ALs <br /> DEPARTMENT USE ONLY f 1 <br /> Application Accepted By Date JJ Area -2 <br /> Grout Inspection By Date Pump Inspection By <br /> r <br /> Destruction Inspection By Date Comments: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED HECK CASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br />