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APPLICATION FOR WELLIPUMP PERMIT r r 51 q3 — I <br /> sowe SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIIT9' <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 3% Mx EAST WEBER AVENUE, STOCKTON, CA gmi-M <br /> (209} 468-3420 <br /> N01I•REFUNOABLE PERMIT EXPFREB i YEAR FROM DATE ISSUED <br /> (comploce <br /> APPLICATION IS IIERE BY MADE TO THE SAN JOAQUIN CDUNIY FOR A PERMIT TO CONSTRUCT iAND/on INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1 T 16.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVrRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSPoR APN4 uhRn ` O <br /> t 4 <br /> p n CITY <br /> OWNER'S NAME_ rn R �'rQ1 • PARCEL SIZE/APNP <br /> ' Lr� <br /> ADDRESS y etT P•1' L <br /> CONTRACTOR u /r�n PHONE <br /> �, ADDRESS .J 1 In• ; (; <br /> SUB CONTRACTOR_ ]1�pr-I-Y" �n^ ------------ <br /> - - LIC# ONE F`�` <br /> ADtrhE86 LICN'5f7-Z7(1,-kg' PHONE ilZ <br /> TYPE O_F WEIUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONrIORING WELL• <br /> ❑ INSTALLATION 11 WELL SYSTEM REPAIR ❑ OTHER <br /> ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL� <br /> ❑New❑Rapeh H.P. DEPTH PUMP SET J <br /> f1YPE OF PUMpj FT. FIRST WATER LEVEL <br /> O <br /> OUT-0F-SERVICE WELL © OEOF'l1VSICAL WELL <br /> ❑ SOIL BORING <br /> DESTRUCTION. � <br /> I'7 rT' <br /> IHTEiFIDED US£ TYPE OF WELL CONSIAUCTIOR SPECIFICATIONS <br /> ❑ INDUSTRIAL OPEN BOTTOM1T A <br /> DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO <br /> ❑ DOMESTICIPRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINGfSTEEUF'VC 1't D <br /> ❑ DIA.OF WELL CASING PUSLIC/MUNICIPAL ❑DRIVEN of o <br /> DEPTH OF GROUT SEAL❑ SPECIFICATION IRRIGATKTN/AG ❑OTHER GROUT SEAL INSTALLED BV S <br /> `K k Yh.�❑ <br /> MONITORING GROUT SEAL PUMPED:SGROUT BRAND NAME 1",em1` E SI Vs ❑Na IpT <br /> CONCRETE PEDESTAL BY ORILLER:m Yee CIN. g <br /> APPROX.DEPTH LOOKING CHESTER BOXlSTOVE PIPE <br /> PROPOSED CDN@TRUCTIONID/@LUNO METHOD; MUD ROTARYS <br /> AIR ROTARY AUGER CABCE <br /> OTHER <br /> 1 HE lEBV CERTIFY THAT t IIAVE PREPARED THIS APFTJCATION AND THAT THE WORK WILL SE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOADUIN COUNTY, HOME OWNER OA LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: <br /> 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT 18 ISSUED,1 814ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'@ HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWINd: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 IRSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPt NfATION LAWS OF <br /> CAUFOShlik THE APPLICANT MUT CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 1341 4"-X42*. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Title <br /> BlSned 71 Y�.r,. (� �►�T (],,,I �] <br /> Data <br /> PLOT PLAN{Draw to Saatal Beate "to <br /> 1. NAMES OF STREETS O ADB NEAREST TO OR BOUNDING THE PROPERTY. <br /> 2, OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PnoPOSEb <br /> 3, DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED EXPANSION OF SEWAGE 04SPOM SYSTEMS. <br /> STRUCTURES,INCLUDING COVERED ARE BI1CH A8 PATIOS,DRIVEWAYS,AND WALKS, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT, <br /> ON THE PROPERTY OR ADJOINING PROPERTY. <br /> DEPARTMENT USE ONLY <br /> Applkallan Aoaepted By bete V ( Ar. <br /> Orout Impaetlan By beta PtmP Iner—tion By <br /> Data <br /> Deetntotlen Inepood"By bete <br /> Comments <br /> ACCOUNTING ONLY: AID/ FACT <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKOMASH RECEIVED By DATE PE WITINERVICE REQUEST NUMBER INVOICE <br /> 3 � bl3 <br /> Pub.Health Serv.-Enviro.173(3196) <br />