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APPLICATION FOR WELLIPUMP PERMIT­ <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br /> (209) 468.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANO/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAI <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSOR APN# �} i�L- y CITY_ J[[7 cites {��) PARCEL SIZE/APYJ! �',/ <br /> OWNER'S NAME ll�._ K.y /�� �Z�)b ADDRESS -S!{-/Y(� Z/J^/ PHONE I %��3-3� <br /> CONTRACTOR /yG nxctc— (2(/ k,( IQ 1 p ADDRESS Zti�J,'r✓ / E-✓�'1'C V J` UC# iCEJ CI[.\/ ?n, PHONE* <br /> SUB CONTRACTOR ADDRESS s / S�A ��- • <br /> uc# PHONE# <br /> TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION <br /> (WELL <br /> '# j <br /> 511 rl �❑New F ep.I, N.P. DEPTH PUMP SET FT. FIRST WATER LEVEL I� t <br /> #TYPE OF PUMP) ((C��' <br /> ��/�Ll� k. rJ✓i,.' C �4--p C1OUT-OF-SERVICEWELL 11GEOPHYSICAL WELL# 11SOIL BORING g <br /> ❑'LDEST`JRUCTION:NSf� I <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ❑ INNDDU5TRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING <br /> 0 DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA.OF WELL CASING D <br /> ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITORING GROUT SEAL PUMPED: ❑YM ❑No CONCRETE PEDESTAL BY DRILLER:❑YM [IN. <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S <br /> PROPOSED CONSTRUCTIOWDRILUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER S� <br /> I 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 ANL <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICI <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIEI <br /> THE 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 OI <br /> CALIFORNIA.' THE CANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INS/P/£� 0N�STT 1200/1 -3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Slpnsd X TItla__ /t_yf/ _,( � 2 Date <br /> PLOT PLAN IDr to So.lol S—I. 'to <br /> /. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. 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. <br /> .. .. <br /> v <br /> .... .. ��. . N, <br /> E � <br /> 4 Izi . . >c� <br /> _. <br /> L _ . <br /> iV"-- fLN <br /> L �.., <br /> :AL. <br />