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car .0 <br />Le, <br /> .111=1•11•11• <br />APPLICATION FOR WELLIPUMP PERMIT <br />SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P 0 BOX 388, 445 N. SAN JOAQUIN ST, STOCKTON, CA 95201.381 <br />1209) 488-3420 <br />NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />ICealplets la 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* 6'. 70 / .4 A. r,/ City 7-J-kV1,i, -).3.2( Parcel Slie/AP4X <br />Owner's Name_11/L, 0 r', .11,, Address .2(.. / //2,.f. WY (7)---)7( Phone 0 k3( <br />Contractor (1), Jaz up Address r%ii %Zc. c T,9;_ L coo 4. k /2 - Phone 0 V/f <br />Sub Contractor Address Lic0 Phone * <br />TYPE OF WELL/PUMP: I] NEW WELL 0 REPLACEMENT WELL IT MONITORING WELL 0 II OTHER <br />II DES'IRUCTION I) OUT-OF-SERVICE WELL IT GEOPHYSICAL WELL 0 El SOIL BORING <br />(I INSTALLATION CI WELL SYSTEM REPAIR (I CROSS-CONNECT REPAIR II VAPOR EXTRACTION WELL 0 <br />5'i,1) II New rl'Repair M.P. „Il't,.., DEPTH PUMP SET 3.5'L.: FT. FIRST WATER LEVEL -29e!, '''' <br />(TYPE OF PUMP) <br />9—› <br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS c, <br />[I INDUSTRIAL El OPEN BOTTOM CIA. OF WELL EXCAVATION CIA. OF CONDUCTOR CASING —.C4 <br />(D <br />0 DOMESTIC/PRIVATE 0 GRAVEL PACK/SIZE TYPE OF CASING/SIEEL/PVC DIA. OF WELL CASING <br />0 PUBLIC/MUNICIPAL n DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br />II IRRIGATION/AG n OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME L.F) <br />0 MONITORING GROUT SEAL PUMPED: CI Yes 0 Na CONCRETE PEDESTAL BY DRILLER: CI Yes IT Ne ......_ ..t...z <br />APPROX. DEPTH LOCKING CHESTER BOX/STOVE PIPE <br />PROPOSED CONSTRUCTIONIDRILUNG METHOD: MUD ROTARY AIR ROTARY AUGER CAgLE OTHER <br />7..!? <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 Joaquil Canty. 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 el, <br />Laws of California.. Contractor's hiring or sub-contracting signature certifies the following: I certify that in the performance <br />of the work for which this permit is issued. I shall employ persons subject to WORKMAN'S CCMPENSATION Laws of California." THE APPLICANT <br />MUST CALL 24 HOURS I ADVANCE FOR ALL REQUIRED INSPECTIONS ATLI:0114444427. Complete drawing at lower area provided. <br />/ <br />Signed X /7274/1 Title 0 LI, 1 <br />PL T PLAN (Draw to Scale Scale " to <br />Names of streets or roads nearest to or bounding the property. G. Location of house sewage disposal system or <br />Outline of the property, giving dimensions and North direction, proposed expansion of sewage disposal systems. <br />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 />DEPARTMENT USE ONLY <br />Date Area _ <br />Grout Inspection By Date Pump Inspection Datef22;a- <br />Destruction Inspection By Date Comments: <br />ACCOUNTING ONLY: RICA ! EAU* <br />PE 0:10ES FEE INFO AMOUNT REMITTED CC-Ii/ICASH RECEIVED EIV DATE PERAUT1SERVICE REQUEST NUMBER INVOICE <br />14 3 ro 145 1,45- iHlii 00 . P5r71 <br /># 000 <br />Application Accepted By