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APPLICATION FOR WELLIPUMP PERMIT 1# v <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIMS <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201388 <br /> (209) 4683420 t j <br /> NONREFUNDABLE 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. y�� p <br /> APN#� 3 a 5 0 <br /> ��— / City i-z>r Parcel Size/APN# <br /> Job Address/or <br /> 7 h 1 Phone #3-6 --10 / L <br /> Owner's Name Address / (��.Q <br /> Contractor <br /> tr1 _ Aui.,ti U Address—/_ uC �!/ +��'� Lic# /(- 237 2 Phone #�fG���YG <br /> Sub Contractor <br /> Address Lic# Phone # <br /> TYPE OF WELL/PUMP: [I NEN WELL [I REPLACEMENT WELL [I MONITORING WELL # [I OTHER <br /> [I DESTRUCTION [J OUT-OF-SERVILE WELL CJ GEOPHYSICAL WELL # [I SOIL BORING <br /> / <br /> 17 INSTALLATION CI WELL SYSTEM REPAIR [7 CROSS-CONNECT REPAIR [1 VAPOR EXTRACTION WELL #__ <br /> Er New [I Repair H.P. I y DEPTH PUMP SET FT. FIRST WATER LEVEL l K <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> DIA. OF WELL EXCAVATION DIA, OF CONDUCTOR CASING <br /> [] INDUSTRIAL [7 OPEN BOTTON DIA. OF WELL CASING <br /> TYPE OF CASING/STEEL/PVC <br /> [?'DOMESTIC/PRIVATE [I GRAVEL PACK/SIZE__ SPECIFICATION ¢, <br /> [I PUBLIC/MUNICIPAL [I DRIVEN DEPTH OF GROUT SEAL <br /> [I IRRIGATION/AG CJ OTHER <br /> GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> [7 MONITORING <br /> GROUT SEAL PUMPED: [] Yes [] No CONCRETE PEDESTAL BY DRILLER: [] Yes [J No <br /> APPROX. DEPTH LOCKING CHESTER BOX/STOVE PIPE -5 <br /> PROPOSED COWSTRUCTIONIORILLING METHOD: MUD ROTARY_ AIR ROTARY_ AUGER_ CABLE_ OTHER_ <br /> 1 hereby certify that ) have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, <br /> otLowing: "I <br /> State Laws, and Rules and Regulations of the San Joaquin County. Home owner or license gent's persons subject toature WWORKMAies N'S fCOMPENSATION <br /> certify that in the performance of the work for which this permit is issued, I shall not Loy peI certfy that in <br /> Laws of California." Contractor's hiring or sub-contracting signature <br /> subject to WORs the'Sfollowing: " Laws oft California theTN RPPL CANT <br /> of the work for which this permit is issued, I shall employ persons <br /> MUST CALL 2�4 nHOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT (209)499-3423. Complette�/drawing at lower area provided. /-ii i� <br /> 1� �-r � ��W-L.i i' itle /f/ Date Sir <br /> Signed X L <br /> PLOT PLAN (Draw to Scale) Scale " to <br /> 4. Location of house sewage disposal system or <br /> 1. Names of streets or roads nearest to or bounding the property. prosed expansion of sewage disposal systems. <br /> 2. Outline of the property, giving dimensions and North direction. 5 Locatpion ofwells within radius of 150 ft. on <br /> 3. Dimensioned outlines and location of all existing and proposed the property or adjoining property. <br /> structures, including covered areas such as patios, driveways, <br /> and walks. <br /> -'L 1i'd i I <br /> gar ' r <br /> DEPARTMENT USE ONLY <br /> D t <br /> "t <br /> Area <br />