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APPLICATION FOR WELLIPUMP PERMIT <br /> `E/ SAN JOAOUIN COUNTY PUBLIC HEALTH SE6SS wES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388, 904 EAST WEBER AVENUE, STOCKTON, CA 95201-'M <br /> (209) 488.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete In Tdplleotol <br /> APPLICATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WON(DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE WRIT SAN <br /> JOAQUIN COUNTY DEVELOPMENT T HAPTER 8-1116.3 AND <br /> THE UANDAR 11 OF)SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSIOR APNS PARCEL SIZE/AM/ <br /> OWNER'S NAME RX& ADDRESS /dIffi &IYLPHONE f� Z ✓ F-� <br /> CONTRACTOR ADDRESS I PHONE B T <br /> SUB CONTRACTOR ADDRESS LIC( PONE S <br /> TYPE OF WELIJPIMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL S ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS CONNECT REPAIR ❑ VAPOR EXTRACTION WELL B J <br /> 11New 11 ReLE <br /> PAIR N.P. DEPTH PUMP SET_FT. FIRST WATER VEL O <br /> (TYPE OF PUMP) <br /> isOUT-OF-GERVICE WELL ❑ GEOPHYSICAL WELL I ❑ BOIL BORING B` <br /> ❑DESTRUCTION: -L <br /> INTENDED USE TYPE OF WELL CONSTRICTION SPECIFICATIONS A N <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D� <br /> ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/6TEEVPVC DIA,OF WELL CASING �J/ �— O(T <br /> ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME EC <br /> ❑ MONITORING I�I GROUT SEAL PUMPED: ElY« 13EDEST <br /> Ne CONCRETE PAL BY DRILLER:❑Y. Ne S"J <br /> APPROX.DEPTH 6 .(�-' LOCKING CHESTER BOX/STOVE PPE S <br /> PROPOSED CONSTRUCTION/MLU( METHOD: MUD VOTARY AIR ROTARY AUGER_CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WALL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AN <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 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORMA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WOK FOR WHICH THT PERMIT 18 ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORMM'e COMPENSATION"We OF <br /> i CALIFORNI%�� � ANT MUST 2 HOURS IN ADVANCE FOR ALL REG=W 1 MTN)NS 4N-te . COMPLETE DRAWING LOWER AMA PROVIDEO. <br /> SIPm!X Tllls ^%1_ <br /> PDT RAN ID,.It,SPM.)S 1. le <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 1. LOCATION OF HOUSE SEWAGE DISPOBFJ SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NOW"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 /> STRUCTURfS.INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> y0 <br /> � QB 4LUIL,Il <br /> 1 <br /> a� <br /> 0 <br /> 0 <br /> '�i VA�EIti.IV <br /> I Ij <br /> 5199- <br /> 7" <br /> H� 1L 1„ <br /> n ------ <br />