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APPLICATION FOR WELL)PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201-388 <br /> (209) 468.3420 <br /> �� EfUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> L'� (Complete in Triplicate) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAO IN C NTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE ST NDARDS OF SAN JOAQUIN CO''jNN�TY L Eµ�,Tj��S�ER�V/ICES,E(y)VIRONMENTAL HEALTH DIVISION. /J <br /> JOB ADDRESS/OR APNI I'� 3 - v u CIT/Y'� .� �n'/� .�PARCEL SIZE/APN• <br /> OWNER'S NAME k ADDRES20 �]]Q�I�J pay� a'm .,1q5 Yip^Cei�� PHONE <br /> CONTRACTOR ADORES / :y 4n 0 � LJC,- / /yPHONE.ZZI --L --� <br /> SUBCONTRACTOR ADDRESS LJCO PHONE• <br /> TYPE OF WELUPUMP. ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL <br /> /J J <br /> / 11New gReo.l, H . 10e DEPTH PUMP SET1202)FT. FIRST WATER LEVEL O <br /> TTYP�PI'Mp' <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL R ❑ SOIL BORING g <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING O <br /> ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEUPVC DIA.OF WELL CASING D <br /> ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITORING GROUT SEAL PUMPED: ❑Yr ❑No CONCRETE PEDESTAL BY DRILLER:❑Ys ❑No .S <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE y <br /> PROPOSED CONSTRUCTION/DRIWNQ METHOD: MUD 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,STATE LAWS.AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'!COMPENSAON LAWS OF <br /> CALIFORNI=THCANT MUST CALL 24 H0 b IN ADVANCE FOR ALL REQUIRED INSPEC AT(209)4613423. COMPLETE DRAWING AT LOWER AREA PROVIDED.Slpned X �� C, Title y- r C �} O.t• <br /> PLOT PLAN IDr to Su1.1 S-1. 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> Q <br /> r► <br /> ko <br /> w <br /> "D � _ - - - - - <br /> 1 �-3 - 3s - � <br /> l 1JAYMEN7 <br /> SEP 13 1995 _ <br /> r'.JBLIC HI;AL T H SERVICE:: <br /> "''VIA0NP✓ENT4L HEALTH DII/i <br /> DEPARTMENT USE ONLY 7 <br /> ' AppllcNlon Accepted By Dae <br /> Z Are. <br /> Grout Irnpect{on BY __. .te PumP I"pectlon BY �� �/ ! Oae�/ /7-L r-- <br />