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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOADUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388,445 N.SAN JOAQUIN ST,STOCKTON,CA 86201-388 <br /> (208)488-3420 <br /> NON.NEFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> IC."ists Is TryNats) <br /> Application is here by swede 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. V/`'� <br /> Job Address/or <br /> //APN# <br /> yr73� y7- /ter„ City Parcel Size/APN# <br /> Owner's Namej2 ILAddress Phone R <br /> Contractor 1116k9 si2 <br /> �— Address , ico1,2�Phone N� <br /> Sub Contractor Address <br /> Lic# Phone # <br /> TYPE OF WELL/PUMP: [7 NEW WELL [] REPLACEMENT WELL [] MONITORING WELL # [] OTHER <br /> [] DESTRUCTION (7 OUT-OF-SERVICE WELL [] GEOPHYSICAL WELL R [] SOIL BORING <br /> G+ [] INSTALLATION )(WELL SYSTEM REPAIR [] CROSS-CONNECT REPAIR [] VAPOR EXTRACTION WELL # <br /> ,J n� [] New )C Repair H.P. DEPTH PUMP SET —FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> [] INDUSTRIAL [7 OPEN BOTTOM DIA. OF WELL EXCAVATION <br /> DIA. OF CONDUCTOR CASING <br /> K DOMESTIC/PRIVATE [] GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA. OF WELL CASING <br /> OUT SEAL SPECIFICATION <br /> DEPTH OF GR <br /> [] PUBLIC/MUNICIPAL I7 DRIVEN 1 <br /> IRRIGATION/AG [1 OTHER <br /> GROUT SEAL INSTALLED BY GROUT BRAND NAME �1 <br /> [] MONITORING GROUT SEAL PUMPED: [] Yes [7 No CONCRETE PEDESTAL BY DRILLER: 17 Yes (1 No W <br /> APPROX.DEPTH ��� f LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTRUCTIONIDNILLING METHBD: MUD ROTARY_AIR ROTARY_AUGER_CABLE—OTHER_ Z <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with an Joaquin County Ordinances, t` <br /> State Laws, and Rules and Regulations of the Sen Joaquin County. Name owner or licensed agent's signature sons t toe certifiesthe <br /> Sf ollowing: - <br /> COMPENSA71ON <br /> certify that in the performance of the work for which this permit is issued, 1 shall not employ pe <br /> Laws of California." Contractor's hiring or subcontracting signature certifies the following: " I certify that in the performance <br /> of the work for which this permit is Issued, I shall employ parsons subject to WORKMAN'S COMPENSATION Laws of California." THEAPPLICANT <br /> MUST CALL 24 MANCE FOR ALL P' NO INS ECTIONS AT ROS)4W34Z3. Complete drawing at Lower area provided. <br /> Title �Fe Date <br /> signed <br /> PLOT PLAN (Draw to Scale) Scale " to <br /> 6. location of house sewage disposal system or <br /> 1. Names of streets or roads nearest to or bounding the property. sed ex cion of sewage disposal system. <br /> Z. Outline of the property, giving dimensions and North direction. r 5. Location of wells within radius of 150 ft. on <br /> 3. Dimensioned outlines end location of all existing and proposed the property or adjoining property. <br /> structures, including covered areas such as patios, driveways, P oPe Y <br /> and walks. <br /> P <br /> pf <br /> 9 <br /> - <br /> _ <br /> f <br /> DEPARTMENT USE ONLY <br /> j"L -C` "r �--� _D to / / 9 Area 2 <br /> Application Accepted By '/ <br /> Grout Inspection By <br /> Date Pump Inspection BY Date*Z /Q <br /> Destruction Inspection By Date Comments: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CASH RECEIVED BY DATE PERMFTpERYICE REQUEST NUMBER INVOICE O <br />