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APPLICATION FOR WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> MOM-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (CempMb M Tripnevis) <br /> APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 19 MADE IN COMPLIANCE WfTH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CtIAPTER 8-i 115.3 ND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> A� N//, <br /> JOB ADDRESS/OR APN/ I Y �'V�/' f 7' C!TV - �Y' PARCEL SIZE/AFNI//rJ <br /> � 7 . <br /> OWNER'S NAME 5 L-t- t /��•ADORE 88i[[ �C ����.���,,.� /� PHONE fAl <br /> CONTRACTOR � {/ �-G� •� �u.\ �,]. ADDRESS ``"�l�A✓`,,/� ��/ ' LICK` L.�L PHONE I ' ��i:JSCe <br /> SVB CONTRACTOR ADORE88 LIC# PHONE 7 <br /> TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL 4 ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ <br /> ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST ATER LEVEL O <br /> (TYPE OF PUMP) <br /> El OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL SOIL BORING 8 <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 2'( DIA.OF CONDUCTOR CASINO O <br /> ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEEL/PVC DIA.OF WELL CASINO D <br /> ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION B <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY L�{-�(�_ GROUT BRAND NAME <br /> 44-TORING / GROUT SEAL PUMPED: ❑Yee (IN. CONCRETE PEDESTAL BY DRILLER:❑Yes ❑Ne S <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S <br /> O <br /> PROPOSED CONSTRVCTION/OWWNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> 1 HE9EBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAOVIN 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 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SU"ONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: '1 CERTIFY THAT IN TILE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED.I SHALL EMPLOY PERSONS 8U9JECT TO WORKMAN'S COMPMSATION LAWS OF <br /> CALIFORNIA.' THECANT MV CA 4 HOURS IN ADVANCE FOR ALL REGED INSPECTIONS AT-[2PROVIDED. <br /> 051 400-2423, COMPLETE DRAWING AT LOWER AREA PVIDED.) L�� <br /> Signed X I�L.J bF�� / J TitleUNIDate '�`�: / <br /> PLOT PLAN IU.aw to Scal.)Scala 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,OIVMNQ DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OVTUNF.S AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,NNCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJONNNM PROPERTY. <br /> : :..... ........ ....... <br /> . <br /> ,r <br /> DEPARTMENT USE ONLY <br /> Applleatlon Accepted By Data / C r1 MY <br /> Grout InaP-11en By Oat. Pump Inapeetlen By Date <br /> Onatruetlen Inep—Oon BY Data <br /> Cemmer.ta�i G��i..r✓ -n "�'�"'� �' .(�^./-�� �i-yP/yj .�1'1.-C� <br /> ACCOUNTING ONLY: AID/ FACT <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKI/CASH RECEIVED By DATE PERMITMEAVICE REQUEST NUMBER INVOICE <br /> Pub Health Serv.-Enviro.173(1/97) <br />