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4kAPPLIGAIIUN rUM VVtLLI'UmP PtHMII <br /> JOADUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201.388 <br /> (209) 488.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Tripiksto► <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 th�tandards of Sen Joaquin County Public Health <br /> Services, Environmental�HealllthDivisiootnn. (� <br /> /!T!Jam/ �'^ /�y l (- C <br /> Job Address/or PN# �l � City Parcel Size/APN# <br /> Owner's Name Address uvl Phone # <br /> Contractor Address Lic# 'S7 )� <br /> 7C �� Phone # <br /> Sub Contractor Address Lic# Phone # <br /> TYPE OF WELL/PUMP: [3 NEW WELL [3 REPLACEMENT WELL [3 MONITORING WELL # (3 OTHER <br /> (3 DESTRUCTION [3 OUT-OF-SERVICE WELL [3 GEOPHYSICAL WELL # 0 SOIL BORING <br /> )CINSTALLATION [3 WELL SYSTEM REPAIR [3 CROSS-CONNECT REPAIR (3 VAPOR EXTRACTION WELL # <br /> V New 0 Repair N.P. DEPTH PUMP SET /c::2 FT. FIRST WATER LEVEL <br /> ( YPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> (3 INDUSTRIAL [3 OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING <br /> ''DOMESTIC/PRIVATE (3 GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA. OF WELL CASING <br /> [3 PUBLIC/MUNICIPAL [3 DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> 0 IRRIGATION/AG [3 OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> (3 MONITORING GROUT SEAL PUMPED: [3 Yes [3 No CONCRETE PEDESTAL BY DRILLER: (3 Yes [3 No <br /> APPROX. DEPTH LOCKING CHESTER BOX/S'SVE PIPE <br /> �7 <br /> PROPOSED CONSTRUCTION►ORILLING 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, <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: " I certify that in the performance <br /> of the work for which this permit is issued, I shat[ employ persons subject to WORKMAN'S COMPENSATION Laws of California." THE APPLICANT <br /> MUST CALL 147 IN ADVANC OR ALL UIRED INSPECTIONS AT(209)488.3423. Complete drawing at Lower area provided. <br /> Signea X Title !O <br /> lP�G Date <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 /> '07 Dtv <br /> i <br /> L <br /> I <br /> I <br />