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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERV, <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 446 N. SAN JOADUIN ST., STOCKTON, CA 96201388 <br /> (209) 4683420 n S <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete is 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. p <br /> Job Address/or APN# 2 3-1 S d a, 4,,-e­c— ' City Parcel Size/APN# <br /> Owner's Name �� f—tfl <br /> "oam Address — Phone #`-'` C �, c.ra ""1-C�-Z. Lic# /(-. 2.37 3 Phone #Contractorw it Address <br /> Sub Contractor Address Lick Phone # <br /> TYPE OF WELL/PUMP: [I NEW WELL [I REPLACEMENT WELL ❑ MONITORING WELL # [I OTHER <br /> [I DESTRUCTION ❑ OUT-OF-SERVICE WELL [I GEOPHYSICAL WELL # [I SOIL BORING <br /> ❑ INSTALLATION [I WELL SYSTEM REPAIR [1 CROSS-CONNECT REPAIR [I VAPOR EXTRACTION WELL #_ <br /> W New ❑ Repair H.P. J L DEPTH PUMP SET i/7=,'! FT. FIRST WATER LEVEL j •� <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> 11 INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING <br /> [DOMESTIC/PRIVATE ❑ GRAVEL PACK/SIZE_ TYPE OF CASING/STEEL/PVC DIA. OF WELL CASING <br /> CT <br /> ❑ PUBLIC/MUNICIPAL [1 DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> [I IRRIGATION/AG [1 OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> [I MONITORING GROUT SEAL PUMPED: [I Yes [INo CONCRETE PEDESTAL BY DRILLER: (IYes ❑ No <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTRUCTIONIORILLING METHOD: MUD ROTARY_ AIR ROTARY_ AUGER_ CABLE_ OTHER_ <br /> 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, �vl` <br /> State Laws, and Rules and Regulations of the San Joaquin County. Home owner or licensed agent's signature certifies the following: "I G <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, I shall employ persons subject to WORKMAN'S COMPENSATION Laws of California." THEAPPLICANT <br /> MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT(2011)4883423. Complete drawing at Lower area provided. <br /> Signed K }�tiZ< -�" 1. Lc-'t/ {�1�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 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 /> J <br /> DEPARTMENT USE ONLY <br /> Application Accepted By____L n'T>''V""�� D�t Area��•� <br />