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APPLICATION FOR WELLIPUMP 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 IvO,ery �� <br /> LL�EiZt_ <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 WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> IOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. �Ay,, <br /> 08 ADDRESS/OR APNA' /,5D 7 �A E/ �0���7 �zAj CITY- //j/ fi(� PARCEL SIZE/APNN /1� <br /> OWNER'S NAME_ZA ��--�/ -I ADDRESS �� PHONE x <br /> I�WC-ADDRESS 1�21,fJ (.,�(�/JL—GC�X uC, Y p PHONE N <br /> SVe CONTRACTOR L ADDRESS C / � y LICK S�PHONE#.Aez�-&-s — <br /> YPE OF WELL/PUMP: NEW WELL }rte REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER---- <br /> INSTALLATION /❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT R.P�AIR ❑ VAPOR EXTRACTION WELL <br /> # <br /> ❑New❑Repair H.P. DEPTH PUMP SETt• 1 FT. FIRST WATER LEVEL /:529 <br /> (TYPE OF PUMP) )/O <br /> / ,[� ❑ OUT WELL J �❑ GEOPHYSICAL WELL# ❑ SOIL BORING <br /> J <br /> DESTRUCTION: /Z "1 �.� �/—A ' �F�/1/!/ il-�� +.Y!/V� 4.0 <br /> INTENDED <br /> 7 NDUSTRIAL �❑1 OPEN BOTTOM IA.OF WELL XCAVATIONTIONbDIA.OF CONDUCTOR CASING �� D <br /> .J DOMESTIC/PRIVATE 1d7 GRAVEL PACK/SIZE TYPE OF CASING/STEELJPVC �7 L.L_� DIA.OF WELL CASING D <br /> ❑�PUBLICIMUNICIPAL /❑vDRIVEN DEPTH OF GROUT SEAL p SPECIFICATION �� ALL R <br /> LL,IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY CA� � /�GROUT BRAND NAME c..._t�IY�jC,J�`- E C <br /> J <br /> 11K��yyy��1���MONITORING GROUT SEAL PUMPED: {� . El No CONCRETE PEDESTAL BY DRILLER:❑Y. 4No S <br /> APPROX. DEPTH ��Q LOCKING CHESTER BOX/STOVE PIPE S z <br /> ROPOSED CONSTRUCTION/DNLUNG METHOD: MVD ROTARY AIR ROTARY AUGER CABLE OTHER , <br /> ,HE9EBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND O <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SU&CONTRACTING SIGNATURE CERTIFIES <br /> HE FOLLOWING: 'I 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 /> AUFORNIA.' TFE UST IN ADVANCE FOR ALL REQUIRED INSPECTIO_IS <br /> AT 1209)4e8 23.�COIMPLETE DRAWING AT LOWER AREA PROVI <br /> Slpned X �.!Lv/O"�'!�� TItle__ �- X6,4' Date (� <br /> PLOT PLAN (Draw to Scale)Scale 'to <br /> NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED v <br /> OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES 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, j <br /> .....:...... <br /> QA <br /> .. . <br /> l <br /> ,c1L)Y1 <br /> ( ..... . <br /> 11 <br />