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APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> \ ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> C} (209) 468-3420 <br /> PN 17 - � [C^`�� NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Triplkeul <br /> APPLICATION 18 HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A KRMIr TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.71118 APPLICATION 18 MADE IN COMPLIANCE WRIT SAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE.CHAPTER B-1 116,3 AND THE STANDARDS OF BAN JOAOUIN COU r'VBLIC IIEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB AODRESB/OR API# ( V N CITY T PARCEL SIZE/APNI <br /> OWNER'S NAME �-' ADDRESS Z7,g F t 1 <br /> �f <br /> � <br /> CONTRACTOR Lu.�,c ADDRESS [ o PHONE <br /> SUB CONTRACTOR ADDRESS r � ,�T UCI PI/ONE <br /> TYPE OF-MIINIJPUMP; ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER <br /> ''ff )q,iNSTALLATPON ❑ WELL 9YSt6M REFAIR ❑ CR088-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL 7 e <br /> ❑New❑Repel, H.P. DEPTH PUMP 8ET[2L—R. FIRST WATER LEVEL D <br /> (TYPE OF PUMP( <br /> ❑ OUT-OF-SERVICE WELL ❑ OEOPIYSICAL WELL# ❑ BOIL BORING A <br /> ❑DESTRUCTION: <br /> INTENDED ULE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D <br /> ❑ DOMESTICIPRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEEL/PVC DIA.OF WELL CASING D <br /> ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITORING GROUT SEAL PUMPED: ❑Yr [IN. CONCRETE PEDESTAL BY DRILLER:❑Yee ❑Ne S <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S <br /> PROPOSED CONETAUCTIONIDPoLUNO 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 JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAOUIN COVNTY. HOME OWNER OR LICENSED AGENT'S BIONATURE 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 OUR-CONTRACTING SIGNATURE CERTIFIES <br /> TM FOLLOWING: "I CERT THAT M E PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT I��{{BBVED,1 SHALL EMPLOY PERSONS SUBJECT TO WOnKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' T C VST 1�IA HOURS IN ADVANCE FOR ALL REOUIR IE71 NS CTIO f"91 l]. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> 8lened X vim- Tltl• \Y/ O.t• <br /> KOT PIAN ID­10 SaNsl bade 'to <br /> 1. NAMES OF 8TREFT9 OR ROADS NEAREST TO On BOUNDING THE PnOPERIY. 1. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAOE DISPPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WTTMN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PAM$,DRIVEWAYS,AND WALXS. ON THE PROPERTY OR ADJOINPM3 PROPERTY. <br /> e <br /> Tb _ <br /> we�-P <br /> Ft JOIt�UiN rdl-INTY <br /> EP4VIRPNmENTALHEP +.Ji'' ION t <br /> ��AllSE ONLY <br /> Applioslkn Aooepted BY D.t. l A. <br /> Grout Impm Ile"BY Dete Pump Irnpeatlon By <br /> Deelnrellen Irwpeelbn BY Oeta <br /> CommdNe: <br /> ACCOUNTING ONLY: AID# FAC/ <br /> PE CODES FEE INFO AMOUNT REMITED IEC ICASH RECEIVED BY DATE / PEr"T/SERVICE REQUEST NUMBFR INVOICE <br />