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'PLICATION FOR WELLIPUMP PERMIT Teci rNQ �v <br /> Sxd JOAQUIN COUNTY PUBLIC HEALTH SERVICES -} <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX M% VA EAST WEBER AVENUE, STOCKTON, CA 95241'988 <br /> 12091460-3420 <br /> NDN-REFUNDAOLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICompbts IR Tripliaata) <br /> APPLICATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICED,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESS/OR AIN# T CITY PARCEL SIZE! # <br /> n n LN�e. <br /> OWNER'S NAME J4 j ADDRESS jD PHONE# _; <br /> f I <br /> CONTRACTOR I, 1 V\ ADDRESS LICR�� „PHONE <br /> i � I <br /> Bus CONTRACTOR ADDRESS C7 Uca z2y PHONE a7 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ REPLACEMENT WELL ❑ MONITORNG WELL# © OTHER <br /> ❑'INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION <br /> �WELL# J <br /> ON.c)Repatr H.P. S DEPTH PUMP SET�,�FT. FIRST WATER LEVEL,l C�.__ ___ 0 <br /> (TYPE OF PUMP] <br /> ❑ OUT-OF-SERVICE WELL - ❑ OEOPHY6ICAL WELLr ❑ Solt-BORNG - 8 <br /> I <br /> ❑DESTRUCTION: <br /> INTENDED USE! TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> 0 INDUSTRIAL ❑OPEN BOTTOM DIA,OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO "�^ D(S <br /> DOMESTICIPRIVAT£ GRAVEL PACKl81ZE � _TYPE OF CAS1NOlSTEELIPVC OtA,OF WELL CASINO 1 D <br /> PUBUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL / SPECIFICATION ✓�7 I <br /> ❑-IRRIGATKONlAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME 'L L...G A. f <br /> ❑ MONITORING 1 GROUT SEAL PUMPED:,$aYr ❑Ne CONCRETE PEDESTAL BY DRILLER:❑Yr ❑Ne S^, <br /> APPROX.DEPTH LOCKING CHESTER BOXISTOVE PIPE <br /> PROPOSED CONSTRUCTIONI MLLING METHOD: MUD ROTARYT 7'�---AIR ROTARY AUGER CABLI -OTHER <br /> I HE9EBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE 1N ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND , <br /> REGULATIONS'OF THE SAN JOAoum COUNTY. HOME OWNER OR LICENSED AGENT'S 81ONATURE CEKtIP1ES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH ' <br /> THIS PERMIT t6 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'l CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL'EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.`;,THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 1205)408.3423. COMPLETE DRAWING'AT LOWER AREA . <br /> Gig 7ltle -�-� 2�t----... . D.ta �,r,y <br /> ' - 1 <br /> PLOT FLAN(Dr.w to Seale)heal. •to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> f 2. OUTLINE O. THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 7. DIMENSIONED OVTUNE.D 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 WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> 1�' W c t( <br /> : ... ;..... ,...... ... ����" :.ABY` ��....... <br /> 9 <br /> ;. .. <br /> .. <br /> ikew <br /> A VIP <br /> 4 too Ae- .. <br /> . d, <br /> Fri <br /> �...... 1 ...!... <br /> A PR996 <br /> fJV <br /> Hr1Nv1 NT <br /> D1iI <br /> DEPARTMENT USE ONLY ( _� <br /> 'S nate - Are. <br /> Appllwtlen Accepted By <br /> h / / L <br /> t^ Orem Impeedvn BY Date f '7 Ptm+p Inspection By Date�7 <br /> Doetrtaatlon Iropectloit BY Date <br /> Cemments: <br /> 9 <br /> 22 <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED HECK/IL ABH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> 3C)y 4I 6L?7321 <br /> o� <br /> I <br />