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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION 1410, <br /> P 0 BOX 388,445 N.SAN JOAQUIN ST.,STOCKTON,CA 95201.388 <br /> {2091 488,3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete In Trip(eats) <br /> Apptication 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 Sen Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br /> Services, Envirormentat Heatth Division. <br /> Job Address/or APN#,3t/S/ '-1 Y �AC✓ Parcel Size/APN# <br /> bv. Line Rd. <br /> Owner's Name f Able/ L J&i:s Address t i 5 Phan. X_$ —yy� <br /> Contractor R P.r CD lir Address 114r CA'LicY , 2/ phone p�p�p7-79y 2 <br /> W", <br /> " <br /> Sub Contractor Address 9 <br /> -5 Lic# phone # <br /> TYPE OF WELL/PUMP: (] NEW WELL [1 REPLACEMENT WELL [] MONITORING WELL # [I OTHER <br /> DESTRUCTION 11 OUT-OF-SERVICE WELL I] GEOPHYSICAL WELL Al [] SOIL BORING <br /> (1 INSTALLATION () WELL SYSTEM REPAIR (] CROSS-CONNECT REPAIR [] VAPOR EXTRACTION WELL # <br /> [] New 11 Repair N.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> (] INDUSTRIAL [I OPEN BOTTOM DIA. OF WELL EXCAVATION DIA, OF CONDUCTOR CASINGJ7 <br /> [1 DOMESTIC/PRIVATE (1 GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA. OF WELL CASING <br /> 11 PUBLIC/MUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> (1 IRRIGATION/AG [] OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> (1 MONITORINGGROUT SEAL PUMPED: [1 Yes II No CONCRETE PEDESTAL BY DRILLER: 0 Yes 11 No <br /> APPROX.DEPTII a5 LOCKING CHESTER 9OX/STOVE PIPE <br /> PROPOSED CONSTRUCTiONIDRILLING METHOD: NUD ROTARY_Alit ROTARY_AUGER_ CABLE_OTHER_ <br /> IQUM4 ,9routeelFrom 4Aie. bt&f,om uA <br /> I hereby cdrtiflf that I have prepared this application and that the work wilt be done in accordance with Sen 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: "1 <br /> certify that in the performance of the work for which this permit is issued, t shall not employ persons subject to WORKMAN'S COMPENSATION <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 persons subject to WORKMAN'S COMPENSATION Laws of California." THE APPLICANT <br /> MUST CALL 24NO SIN ADVANCE FOR ALL REQUIRED INSPECTIONS AT(2011468,3423. Complete drawing at lower area provided. <br /> Signed X _ ``2 � ����....._. Title �2L /�♦•��J 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 S. Location of welts within radius of 150 ft. on <br /> structures, including covered areas such as patios, driveways, the property or adjoining property. <br /> and watks. <br /> PF <br /> —LLL I <br /> 7 D A TMENT USE ONLY �ql 9 <br /> Application Accepted By pat P l ( Area <br /> Grout Inspection y Dete�• <br /> Pump Inspection By Date <br /> Destruction Inspection By Date Comments: <br /> ACCOUNTING ONLY: AID# FAC* <br /> PE CODES FEEIRFO AMOUNT REMITTED CH N ASH RECEIVED BY DATE PERMITj$ERYICE REQUEST NUMBER INVOICE <br /> naa- 4)rn 12-ii s' 10 o s <br />