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APPLICATION FOR WELLIPUMP PERMIT " <br /> 3AH JOAOUIN COUNTY PUBLIC HEALTH.SERVIt <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388,.446.N. SAN JOAQUIN ST., STOCKTON, CA 96201.388 <br /> " (209) 468.3420 ! " <br /> f <br /> RON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Momplets in Tripikat41) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY.FOR A PERMIT TO CONSTRUCT ANWOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT.TITLE,CHAPrER�9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSIOR APN# 116 �ilr` .�� 1TI.s`J)'lr7J2f� !-��14e CITY. _JG<)r�^ N# <br /> PARCELSIZE/AP <br /> OWNER'S NAME &zo ADDRESS 4L_Unicom', S ?Zt'cZSCO ,ic-"&, yj� PHONE aoC)/7Z,-7d" <br /> CONTRACTOR ADDRESS Jl �JwuC# PHONE <br /> SUBCONTRACTOR� 17.✓, DIYICIL C.1_ .,.. ADDRESS Z12t+_ �i)ff7dy1 111,�6_C _ UCI G--s7 PHONECI <br /> [ o- <br /> TYPE OF WELUPUMP ❑ NEW WELL ❑ REPLACEMENT WELL - ❑"MONITORING WELL I j -_ ❑ OTHER - <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑.CROSS-CONNECT REPAIR 'i ❑ VAPOR EXTRACTION WELL:I J <br /> ❑New Repair N.P. _ D£PrH-PUMP SET FT. FIRST WATER LEVEL _ p <br /> (TYPE OF PUMP) <br /> ❑ OUT-0F-SERVICE WELL ❑.GEOPHYSICAL WELL I -- SOIL BORING ? L'/iL1lJ[,dt S <br /> I <br /> - ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING - p <br /> t ❑ DOMESTICIPRIVATE ❑GRAVEL PACKISIZE TYPE OF CASINGISTEEUPVC DIA.OF WELL CASING p <br /> ❑ PUBLICIMUNICIPAL ❑DRIVEN - DEPTH OF GROUT SEAL SPECIFICATION _ p <br /> ❑ IRRIGATION/AG ❑OTHER - GROUT SEAL INSTALLED BY GROUT BAANO NAME E <br /> ❑ MONITORING - GROUT SEAL PUMPED: ❑Yee ❑No 1 CONCRETE PEDESTAL BY DRILLER:❑Ya ,[IN. - S <br /> APPROX.DEPTH LOCKING CHESTER BOXISTOVE PIPE S <br /> PROPOSED CONSTRUCTIONIDrtlLLING METHOD: MUD ROTARY AIR ROTARY AUGER 'CABLE -OTHER <br /> i <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> _ REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE V40FK FOR WHICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING; "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL RE6UIRED INSPECTIONS AT t206146414423. COMPLETE DRAWING AT LOWER AREA PROVIDED./ <br /> Signed X Title <br /> PLOT PAN{Drew to$Wei Scale •to - - <br /> 7, 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,GIVING DIMENSIONS AND NORTH DIRECTION. _ - EXPANSION OF SEWAGE DISPOSAL SYSTEMS. - <br /> 3, DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WALKS. 'i ON THE PROPERTY OR ADJOINING PROPERTY. <br /> .................... <br />