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i <br /> APPLICATION FOR WELLJPUMP'PERMI' <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SER'r 3 <br /> ENVIRONMENTAL HEALTH DIVISION j <br /> P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCXTON, CA 9520.1.388 ' <br /> (2091488-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICemplata 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. <br /> Job Address/or APN#' 39c42 rCity Parcel Size/APR# <br /> IJ <br /> Owner's Namely Address : Phone # <br /> Contractor Address j� 1 -��167,;,tfOLic# Phone # z <br /> Sub Contractor Address Lic# Phone # <br /> TYPE OF WELL/PUMP; (1 N&UELL 11 REPLACEMENT WELL [I MONITORING WELL # [I OTHER <br /> 0 DESTRUCTION 0 OUT-OF-SERVICE WELL [I GEOPHYSICAL WELL # [1 SOIL BORING <br /> INSTALLATION 0 WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR 11 VAPOR EXTRACTION WELL # <br /> ]a— or New [I Repair H.P. 8- DEPTH PUMP SET/YdD FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> I <br /> INTENDED USE TYPE OF WELL CMINUCTiON Se[CIFICATIONS <br /> 0 INDUSTRIAL 0 OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING <br /> DOMESTIC/PRIVATE [1 GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA. OF WELL CASING ! <br /> 0 PUBLIC/MUNICIPAL [1 DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> [1 IRRIGATION/AG [1 OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> Q MONITORING GROUT SEAL PUMPED; [1 Yes 0 No CONCRETE PEDESTAL BY DRILLER: 0 Yes 0 No- j <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE 4-11 <br /> I <br /> PROPOSED CONSTAUCTIONIORILUNO METHOD: MUD R07ARY 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: " 1 certify that in the performance S <br /> of the work for which this permit is issued, I shall employ persons subject to WORKMAN'S COMPENSATION Laws of California.H THE APPLICANT <br /> MUST CALL 24 HOURS ADVANCE FOR ALL REQUIRED INSPECTIONS AT(209)488.7427. Complete drawing atL er area provided. <br /> Signed X ' Title Date Q <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 welks. <br /> r1 � <br /> y Vi - <br /> 1 VI-L' <br /> 1 6 Q . <br /> EN Irl} 41[-"V 1 I r`I' ',,i`..TI'S 0,tYli 010N <br /> • n <br /> — DEPARTMENT.USE-ONLY,,.,_.,,,.,,,,,.}. <br /> 21 Application Accepted By - D toit r ff Area -1L� <br /> Grout Inspection By Date Pump Inspection By Date�Z ZZ <br /> Destruction Inspection By Date Comments: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED EC CASH RECEIVED,BY DATE PEAMITI8ERVICE REQUEST NUMBER INVOICE <br /> z v s '00 LW1. 3 0 b o <br />