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APPLICATION FOR WELLIPUAIIP PERMIT �� -- <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N.SAN JOAOUIN ST,STOCKTON,CA 95201488 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Camplste be Tr}Neaw) <br /> Application is here by mode to the San Joaquin County for a permit to construct and/or install the work described. This application is <br /> made in crmpliance with San Joaquin County Development Title, Chapter 9.1115.3 and the Standards of Sen Joaquin County Pblic Health <br /> Services, Envirorreenttal Health Division. `` (t�� ffj`_ <br /> Job Address/or APNA�"'b��1U o w ell �d G n i..t� city &A-d ParceL Size/APN#_ <br /> Owner's Nerve rIy/ �Qll /YLJPtddress � �Ph onr # 2 <br /> ContractorAddress AQ A72-7 Lic# 623/3 <br /> Sub Contractor Address lir# Phone # <br /> TYPE OF WELL/PUMP: [] N:W WELL [I REPLACEMENT WELL [I MONITORING WELL # [1 OTriER <br /> [] DESTRUCTION (] CUT-OF-SERVICE WELL [I GEOPHYSICAL WELL # [] SOIL BORING <br /> (] INSTA:.LATION U WELL SYSTEM REPAIR [1 CROSS-COMNECT REPAIR [1 VAPOR EXTRACTION WELL # <br /> &!*WfA New V"'Repeir N.P. /n/] DEPTH PUMP SET24W FT. FIRST WATER LEVEL 3J , <br /> YPE OF PUMP <br /> INTENDED USE TYPE OF YiEL CONSTRUCTION SPECIFICATIONS Q_ <br /> INDUSTRIAL [1 OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING .� <br /> [I DOMESTIC/PRIVATE ❑ GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PV[ DIA. OF WELL CASING <br /> ra PUBLIC/NUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL SPE(11LCA➢ <br /> [] IRRIGATION/AG [I OTHER GROUT SEAL INSTALLED BY _ GROI�j�{ 1 <br /> [1 MONITORING GROUT SEAL PUMPED: [] Yes [) No COMLI[EBILLER: 0Yes ❑ No <br /> APPROX.DEPTH LOCKING CHESTER BOX/S70VE PIPE` SEP <br /> (� '4 1- 2 7 1994 <br /> PROPOSED CDUST RUCTIONIDRill.LING METHOD: MID ROTARY__AIR ROTARY_AUGER_ CABLE_07H$,�N JOAQUIN COUNTY <br /> PU=HEALTH SERVICEIicinNS <br /> I hereby certify that I have prepared this spptication actor n <br /> and that the work will be done in ce It en osquin wSCounty Ordinances, <br /> state Laws, and RuteguI.atIons <br /> of the San Joaquin County. Hage owner or licensed agent's signature certifies the following: "I <br /> certify that in perfor a of the work for which this permit is issued, I shall not employ persons subject to WOI/OMAN'S COMPENSATION <br /> Laws of Calif nia." Contr ctor's hiring or sIb-contract- signature certifies the following: l certify that in the performance <br /> of the work or which ff <br /> ' is issued, all persons subject to WDRKMAN'S COMPENSATION Laws of California." THE APPLICANT <br /> MUST CALL 4 HOURS IN ALL QUI 401T>�?. Complete drawing a ower arae ovided. p <br /> Signed X <br /> ( Title <br /> PLOT PLAN (Draw to scale) Scale " to <br /> 1. Names of streets or roads nearest to or bounding the property. 4. Location of house sewage disposal system or <br /> 2. Outline of the property, giving dimensions and North direction. proposed expansion of sewage disposal systems. <br /> 3. Dimensioned outlines and location of ell existing and proposed 5. Location of wells within radius of 150 ft. on <br /> structures, including covered areas such as patios, driveways, the property or adjoining property. <br /> and walks. AJ <br /> i <br /> 8 <br /> DEPARTMENT USE ONLY <br /> Date �_ Arwjn� <br /> Application Accepter! By P <br /> Date // <br /> Grout inspection 61YDate PunQ Inspection By '-�— `f <br /> Destruction Inspection BY Date Comments: <br /> ACCOUNTIGQ ONLY: AID# FAC# <br /> PE Vi DES FEE INFO AMOUNT REYRTED CNf iMCA8H RECEIVED BY qEt�-VqEjUEST NUMBER INV06CA <br /> 5 <br /> b2 <br /> J <br />