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APPLICATION FOR WELL)PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201-388 <br /> (209) 468-3420 <br /> NON-REFUNDABLE 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 WORT(DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> IOAVUeN COL'VToY DEVELOPMENT TITLE, <br /> TITTLE,CHAPTER 9--1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB �(y K'E"IOR A +r/(r1l.K�.�r/-} // CITY A�CA <br /> ! Q PARCEL SIZE/APN#C7 �.r•��S <br /> OWWi S NAME(/N��.wA-�� 1CFRII/ l[T,��( ADDRESS 7 UjV-7���,^�ILPJACC yy X�� �,��� <br /> CONTRACTOR CAL(A/1-75 / / i T/C ADDRESS3DD S.KILR�,�T/ /(AL.Y/� iC-AAV - PHONE 1 j(0 �y <br /> SUR CONTRACTOR .p� ADDRESS ✓ LIC# PHONE# <br /> TYPE OF WELL/PUMP: .Cl NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL d ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CRO98-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# <br /> (TYPE OF PUMP) 11New IJRepolt H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL D <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL A ❑ SOIL BORING B <br /> ❑DESTRUCTION: <br /> �INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION{ A <br /> J61-INDUSTRIAL ,.�❑1 OPEN BOTTOM DIA.OF WELL EXCAVATION__ `2 /Mr� DIA.OF CONDUCTOR CASING <br /> �— D <br /> ❑ DOMESTIC/PRIVATE GRAVEL PACKISIZE�X TYPE OF CASINGISTEEL/PVC ?V r DIA.OF WELL CASING D <br /> ❑ PUSLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL_ SPECIFICATION S�/-,�lQ A <br /> ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED SYCC1/LL__!A/f-,61!- GROUT BRAND NAME �J F <br /> ❑ MONITORING / GROUT SEAL PUMPED:MY-- ❑No M1CONCRETE PEDESTAL BY DRILLFR:❑Ys;sw0 5 <br /> APPROX.DEPTH z(p /�- LOCKING CHESTER BOX/STOVE PIPE S t !1 <br /> PROPOSED CONSTRUCTIONIDRILLINO METHOD: MVD ROTARY_ AIR ROTARY AUGER CABLE OTHER C) <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARF.D THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAGUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH T <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES /1 <br /> THE FOLLOWING: '1 CERTI THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENe ATION LAWS OF <br /> CALIFORNI E C T MUST C LL 24 HOURS IN ADVANCE FOR ALL REQUIRED INW IONIAT oel 4e8 J422. COMPLETE DRAWING AT LOWER AREA PRO TOED. <br /> 8lpned X Tltle Do? <br /> PLOT PLAN ID,*w to Sahel Scolo 'to � <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> PROPOSED \y <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS T ONE HUNDRED FIFTY FT. -G <br /> STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> __. . ........'..... '... .. <br /> ;.... <br /> < _ ..yn...o_H`+ 'o+►virwe,.,w.....hs.+�s -1-..-od,.r., w.M..,..•.....b, <br /> _ :..... .._. _. :..._.i. :.. _ - ....... <br /> J ................. <br /> ,.......... <br /> _. <br /> l <br /> : <br /> s.............:................ ... — <br /> . <br /> C <br /> E <br /> DEPARTMENT USE ONLY <br /> Applieotlon Aoeeptad By '7 <br /> Dot. A­ <br /> Grout Inspection Sy Date Pump Inspeotlpn By <br /> Dote <br /> Dootr-tlon I-peetIo By <br /> Dote <br /> Comments: <br /> 3 rpill" <br /> ACCOUNTING ONLY: AID/ FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED C EC /CASH RECEIVED By DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> I <br />