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SAPPLICATION FOR WELLIPUMP PERMIT r' <br /> AN JOAOUIN COUNTY PUBLIC HEALTH SERVI. 1 ' <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 3118, 446 N. SAN JOAQUIN ST., STOCKTON, CA 95201-368 <br /> (209) 468.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> lComplete In Tripliaats) <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 4-1115.3 and the Standards of San Joaquin County Public Health <br /> Services, Environmental Health Division. 7 <br /> Job Address/or APN City / L V Parcel Size/APN# <br /> Owner's Name AddressINWkc Phone # ��IV <br /> Contractor Q. <br /> Address Lic# 1G;IL Phone # l <br /> Sub Contractor_ / Address Lic# Phone # <br /> TYPE OF WELL/PUMP: [3 NEW WELL [1 REPLACEMENT WELL E] MONITORING WELL # [3 OTHER <br /> 0 DESTRUCTION E3 OUT-OF-SERVICE WELL [3 GEOPHYSICAL WELL # [3 SOIL BORING <br /> INSTALLATION [3 WELL SYS EM REPAIR (3 CROSS-CONNECT REPAIR [1 VAPOR EXTRACTION Wr L # <br /> ew (3 Repair H.P. DEPTH PUMP SET 650 FT. FIRST WATER LEVEL„_ <br /> (TYPT OF P P) <br /> INTENDED_USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> E3 INDUSTRIAL [I OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING (`W <br /> ESTIC/PRIVATE [3 GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA. OF WELL CASING C3 <br /> (3 PUBLIC/MUNICIPAL [3 DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> E3 IRRIGATION/AG [3 OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> [3 MONITORING GROUT SEAL PUMPED: [I Yes E3 No CONCRETE PEDESTAL BY DRILLER: E1 Yes 0 No <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE J <br /> PROPOSED CONSTRUCTIONIDRILLING METH 00: MUD ROTARY_ AIR ROTARY,,,-,_ AUGER-^ CABLE_ OTHER„ �C <br /> I hereby certify that 1 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 (1 <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 COMPENSATIDN Laws of California." THE APPLICANT <br /> MUST CALL 24 H RS IN ADVANR ALL REQUIRED INSPECTIONS AT(2011 468.3428. Complete drawing at ower area provided. <br /> dmq <br /> Signed X Title Dat <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 /> 141 <br /> L <br /> DEPARTMENT USE ONLY <br /> B Date Area <br /> Application Acceptedy <br /> Grout Inspection By Date Pump Inspection'S net, <br /> Destruction Inspection By Date Comments- <br /> ACCO UNTING <br /> omments:ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOU T REMITTED CHECK CASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> 4S b ;t ff oo L4H Id SDaA6 <br />