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APPLICATION FOR WELIJPUMP PERMIT <br /> ' I SAN JOACMIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> COPY <br /> P 0 110X 388,446 N.SAN JOAQUIN ST,STOCKTON,CA 86201.388(2091408 <br /> 3420 <br /> NON.REFUNDAStE PERMIT EXPIRES T YEAR FROM DATEiSSUED <br /> iCamplets Is Wiata) <br /> Application is here by made to the San Joarau[n County for a permit to construct end/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 Heaith <br /> Services, Envirormental Health Division. <br /> Job Address/or APM* City /// /T'� Parce( Size/APHO2�LE�. <br /> _ s+�� Grti <br /> Owners Home A ress r/Jl' dl Phone i <br /> Contractor Address xt'/ Y 1j& Phone '1� /7//c'—f <br /> Sub Contractor Address Licl Phone <br /> TYPE OF wUlLPUMP:. X,NEN WELL [I REPLACEMENT WELL O MONITORING WELL 0 O OTHER <br /> [I DESTRUCTION 17 OUT-OF-SERVICE WELL [I GEOPHYSICAL WELL N U SOIL BORING <br /> INSTALLATION [T WELL SYSTEM REPAIR [I CROSS-CONNECT REPAIR [I VAPOR EXTRACTION YELL ! <br /> V Mew [) Repair H.P. DEPTH Pt1MP SET FT. FIRST WATER LEVEL <br /> (TYPE OF Pl1MP) - <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> I] INOUSTRIAL [I OPEN BOTTOM !'', DIA. OF WELL EXCAVATION / DIA.-of CONDUCTOR CASING <br /> [I DOMESTIC/PRIVATE GRAVEL PACK/S[ZEr��2 TYPE OF CASING/STEEL/PVC DIA. OF WELL-CASING la-/if/CL <br /> I t{-PUBLIC/M MICIPAL [I DRIVEN DEPTH OF GROUT SEAL, -SPECIFICATION„ gna <br /> `h [I TRRIGATION/AG ❑ OTHER GROAT SEAL INSTALLED BY GROUT BRAND NAME <br /> MONITORING GROUT SEAL PUMPED: [I Yes 0 No CONCRETE PEDESTAL BY DRILLER: I] Yes [) No <br /> APPROX.B�iil LOCKING CHESTER BOX/STOVE PIPE <br /> U PRDPOSED CONSTRUCTIOMIONiLUND METHOD: MLA ROTARY, 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, end Rules and Regulations of the San Joaquin County. Now owner or ticensed 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 person subject to WORK14AMIS 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 permi is issued, I shall emptoy persons subject to WORKMAN'S COMPENSATION Laws of California." THEAPPUCANT <br /> MUST CALL 2 M AOVANC LL REQUIRED INSPECTIONS AT(201)4N1.3423_ Caoptete drawing at tower area provided. <br /> Signed x TitlefN�L!/t D� 7 <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 di s s syatm or <br /> 2. Outline of the property, giving dimensions and North direction. proposed expansion ,Wow.I system. <br /> 3. Dimensioned outlines and location of aLt.existing and proposed 5. Location of wells i yqff��150 ft. on <br /> structures, inctuding covered areas such as patios, driveways, the property or are �W <br /> and walks. nr.1J 3 10 <br /> S N J AQ Lh6 g <br /> !' Mr <br /> tdE T D4Y$l <br /> l / <br /> Ilk <br /> 1 <br /> 5LA <br /> If <br /> DEPARTMENT USE_DMLY <br /> Application Accepted By DateAredT <br /> G t inspection B - etRC��P Inspection B�YeT,..-' - �.Dpte <br /> Destruction Inspection SY Date Comments: &kl-4'f/y' <br /> ACCOUNTING ONLY: AID/ FACN �� i[✓/.rf.00-r7.lf�.�1 oT�'���7� <br /> PE CODES FEEINFO AMOUNT REMITTED EC CRON RECEIVED BY DATE PERMITiSERVICE REQUEST NUMBER INVOICE <br /> ID L ii �Z <br />