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APPLICATION FOR WELLJPUMP 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 ' r <br /> (209) 488.3420 Al b b 0 O L4 I I <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 <br /> made in compliance with San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br /> Services, Environmental Health Division. <br /> Job Address/or APN# 16035 Ray Road City Lnrli Parcel Size/APN# 20 acres <br /> owner's Name Fritz Grupe Address 3255 W March Lane Phone # 473-6000 <br /> Contractor Cl ark Wal 1 Address 9099 F Chart-Pr Lic# 371 560 Phone # 462-7676 <br /> " Sub Contractor Address Lic# Phone # <br /> TYPE OF WELL/PUMP: X Q XNEW WELL ❑ REPLACEMENT WELL [I MONITORING WELL #_ ❑ OTHER <br /> [1 DESTRUCTION [I OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL # (I SOIL BORING <br /> XIS XINSTALLATION ❑ WELL SYSTEM REPAIR [) CROSS-CONNECT REPAIR [I VAPOR EXTRACTION WELL # <br /> Sub 11 New ❑ Repair H.P. 5 DEPTH PUMP SET 1 0 5 FT. FIRST WATER LEVEL <br /> ,TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> [I INDUSTRIAL [I OPEN BOTTOM DIA. OF WELL EXCAVATION 14 DIA. OF CONDUCTOR CASING <br /> X Ed DOMESTIC/PRIVATE W GRAVEL PACK/SIZE1 /4—8 TYPE OF CASING/STEEL/PVC PVC--0IA. OF WELL CASING 6 5 Z 8 <br /> PUBLIC/MUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL inn ' SPECIFICATION N n 1 2 �. <br /> IRRIGATION/AG ❑ OTHER GROUT SEAL INSTALLED BY C I a r h GROUT BRAND NAME <br /> Q <br /> [) MONITORING GROUT SEAL PUMPED: [) Yes [I No CONCRETE PEDESTAL BY DRILLER: [I Yes ❑ No W <br /> APPROX. DEPTH 1 6() 1 LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTRUCTIONIORILLING METHOD: MUD ROTARYx_ AIR ROTARY_ AUGER_ CABLE_ OTHER_ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, <br /> State Laws, and Rules and Regulations of the San Joaquin County. Home owner or licensed agent's signature certifies the following: "I <br /> certify that in the performance of the work for which this permit is issued, I shall not employ persons subject to WORKMAN'S COMPENSATION <br /> - Laws of California." Contractor's hiring or sub-contracting signature certifies the following: " I certify that in the performance <br /> of the work for which this permit is issued, I shall employ persons subject to WORKMAN'S COMPENSATION Laws of California." THE APPLICANT r7 <br /> MUST CALL 24 HOURS IN AADVANCE F R,fLL-R,E/DYIIRREDD INSP CTIONS AT(208)488-3423. Complete drawing at lower area provided. ll�' <br /> Signed X fl[ . / tz' TitleVP Clark Well D te e <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 /> s 2. Outline of the property, giving dimensions and North direction. proposed expansion of sewage disposal systems. <br /> 3. Dimensioned outlines and location of all 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. <br /> re- 2 SJbJVis5n12U are <br /> ak <br /> vel ~� <br /> ankf`e: Tal tt <br /> Vit.-S <br /> E VIR� fdf�1 .Nl L ri ,aLi i f'1 � J <br />