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APPLICATION FOR WELLIPUMP PERMIT <br /> AN JOAQUIN COUNTY PUBLIC HEALTH SERVIC Oa/a <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201388 <br /> 12091 4683420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 <br /> /Div�i/s Division. <br /> Job Address/or APN# e"',/, �-b !� G / �// City Z� Parcel Size/APN# <br /> c <br /> Owner's Name r� -//b[�/ a i.vi/ Address a� Phone # <br /> Contractor w!,(/1 9 Address (��19 Phone #5421 <br /> Sub Contractor Address Lic# Phone # <br /> TYPE OF WELL/PUMP: [I NEN WELL [I REPLACEMENT WELL [I MONITORING WELL # [I OTHER <br /> [I DESTRUCTION [I OUT-OF-SERVICE WELL [I GEOPHYSICAL WELL # [I SOIL BORING <br /> [I INSTALLATION ❑ WELL SYSTEM REPAIR [I CROSS-CONNECT REPAIR [I VAPOR EXTRACTION WELL # <br /> S1S�- [I New X Repair N.P. 57-- DEPTH PUMP SET SFT. FIRST WATER LEVEL_ <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> [I INDUSTRIAL [I OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING <br /> DOMESTIC/PRIVATE [I GRAVEL PACK/SIZE_ TYPE OF CASING/STEEL/PVL DIA. OF WELL CASING <br /> II PUBLIC/MUNICIPAL Cl DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> [I IRRIGATION/AG [I OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> MONITORING ! GROUT SEAL PUMPED: [I Yes [I No CONCRETE PEDESTAL BY DRILLER: [I Yes [I No <br /> y <br /> APPROX. DEPTH_ ` S LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTRUCTIONIDRILLING METHOD: MUD ROTARY_ AIR ROTARY_ AUGER_ CABLE_ OTHER_ <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, t' <br /> State Laws, and Rules and Regulations of the San Joaquin County. Home owner or licensed agent's signature certifies the following: "I 0 <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 G <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." THEAPPLICANT <br /> MUST CALL 24 HOURS IN ADVANCE FOR ALL REDUIREO INSPECTIONS AT (203) 4883423. Complete drawing at Lower area provided. <br /> �J /D <br /> Signed X Title �F�s _ Date <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 W' <br /> Fcj t, P r <br /> NOV2 397 <br /> P LIC EAL �. <br /> E VIR N H' �' .g <br /> DEPARTMENT USE ONLY Ir I[ <br /> Date I I� Aren� <br /> Application Accented BY - ��"-----' fIn /i/ -7 <br /> pa.e Punp Inspection By ( �.�� Date '-/ <br /> Grout Inspection 8y <br /> Destruction Inspection By Date Comments: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHEC CASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> q7 a Fa9to <br />