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APPLICATION FOR WELLIPUMP PERMIT <br /> -SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICET <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 95201-388 <br /> (209) 4683420 - <br /> MONREFUNDABLE PERMIT EXPIRES I YEAR FROM GATE ISSUED <br /> (Complete is Triplicate) <br /> Application is here by made to the San Joaquin County for a permit to construct ale/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#:-2 _3a5 0 �, )� �«„ City .C.c-��vY...ri-er— Parcel Size/APN# <br /> Owner's Nane 9 -I��V--d/' Address_//��s�.II-��_ �) C Phone # - /0 <br /> Contractor U� U Address_ S.� u�• JC.4-� 7 f,~•'�, Lic# /L-. 137_ Phone #x�C.�a-'`/4,d�' <br /> Sub Contractor Address Lic# Phone # <br /> TYPE OF WELL/PUMP: [I NEN WELL ❑ REPLACEMENT WELL [I MONITORING WELL # [I OTHER <br /> ❑ DESTRUCTION ❑ OUT-OF-SERVICE WELL [1 GEOPHYSICAL WELL # [I SOIL BORING <br /> ❑ INSTALLATION [1 WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL # <br /> -.�ti✓� LJ-New ❑ Repair H.P. L DEPTH PUMP SET �/Y'7/ 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 DIA. OF CONDUCTOR CASING <br /> [,'DOMESTIC/PRIVATE [I GRAVEL PACK/SIZE_ TYPE OF LASING/STEEL/PVC DIA. OF WELL CASING <br /> 11 PUBLIC/MUNICIPAL 0 DRIVEN DEPTH OF GROUT SEAL SPECIFICATION w <br /> [I IRRIGATION/AG [I OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME Y� <br /> MONITORING GROUT SEAL PUMPED: (I Yes ❑ No CONCRETE PEDESTAL BY DRILLER: ❑ Yes ❑ No <br /> APPROX. DEPTH LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTRUCTIONIORILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> — <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: "1 <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: " 1 certify that in the performance <br /> of the work for which this permit is issued, 1 shall employ persons subject to WORKMAN'S COMPENSATION Laws of California." THEAPPLICANT <br /> MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12091469-3423. Complete drawing at lower area provided. <br /> Signed % �t-% �'I-aZ�� /'t�Title Date <br /> —�-�y- <br /> PLOT PLAN (Draw to Scale) Scale " to 77 1F- <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 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 /> Cl­ej P17 104 <br /> Il 'A tip 1' ri, <br /> i <br />