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APPLICATION iF08 WELLJPUMP pERMIT <br /> SAN JOAQUIN COUNTY PUg1rC HEALTH�� a. <br /> P,0• BOX 38a. gpq EAST y g rat HEALTH orvrsro)r ms's <br /> (209) 489-3420 Et s�cK]7oN, cA se <br /> APPLICATION IS"ERE By MADE TO THE SAN JOAOUIN COUNTY�FOR A�PERRRLE PERMIT EXPIRES YEAR F$Q(tR <br /> JOAOUIN Cou (Com B DATE ISSUED <br /> NTY DEVELOPMENT r P �� TFtplieatrl <br /> rrLL.CHAPTER <br /> 9-1115.3 PERMIT TO CONSTRUCT ANWOR INSTALL <br /> JOB ADORE88lOR APN w , 1� AND THE STANDARDS OF SAN JOAQUIN COUNTY THE WORK pESCRIBEO.THIS APPLICATION <br /> // ` r&*M�* CLIC((HEALTH SERVICES,ENVIRONM NTLtHE��H p�8 ON IANCE WITH SAN <br /> OWNER'SN�R � <br /> V d <br /> ITY 1-rtl� <br /> r/,/` ' . PARC`L etZ�A I. 23z�a 3 <br /> CONTRACTOAbORES6"(p �i Lir 4 Q <br /> dS! �7�, sNONE <br /> SUB CONTRAGTOL �4 r0� l Q ate+ ,L1CN, �t[q PHONE A' Z�� �J�Z <br /> ADDRESS IJC�I PHaNE a.J�_Y <br /> TYPE OF WELLJPUMP;, ❑ NEW WELL ❑ REPLACEMENT WELL <br /> ❑ MONITORING WELL 1 ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL <br /> 11 J <br /> New❑Rapalr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP( ❑ ,RS p OUT-0F•SERVICE WELL 11 GEOPHYSICAL WELLI! Lp�SOIL BORING B <br /> 13 DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ iNDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO p <br /> ❑ DOMESTIC/PRIVATE ❑GRAVEL PACKISIZE TYPE OF CASINGISTEELIPVC DIA.OF WELL CASING p <br /> ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BV GROUT BRAND NAME E <br /> ❑ MONttOR1NG GROUT SEAL PUMPED: ❑Yee 0 N CONCRETE PEDESTAL BY DRILLER:❑Yw 13N- <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPES <br /> PROPOSED CONSTRUCTIONlDRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT TI4E WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:9 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED.I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$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.' T" <br /> CANT MUSTCALL 24 HOURS IN ADVANCE TOR ALL REQUIRED tNSPECTIONi A 120SI 4"4422. COMPLET DRAWINO AT LOWER AREA PROVIDED. <br /> 819ned X TI"o OA-Cl (,-�,6 Data <br /> PLOT PIAN(OZ <br /> to So"Sule "to Ili <br /> 1. NAMES OF STREET R ADS NEAREST TO OR SOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PRO ,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6. LOCATION OF WELLS Wr H1H RAb1US OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> DEPARTMENT USE ONLY rt I <br /> Apprrc.tien Accepted By Data it- - `Y Ara■ + <br /> Grout Impaction By Data, Pump Inspection By Date . <br /> f <br /> Deatructlen Inepectlon By Date <br /> Comment: <br /> ACCOUNTING ONLY: AIDS FAC/ <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKRICASH RECEIVED By DATE PEPMITISERVICE REQUEST NUMBER_ INVOICE <br /> 3(A7 li'I 0 IX(Oli <br />