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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 446 N. SAN JOAOUIN ST, STOCKTON, CA 96201-388 <br /> 12091 468.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCNBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSOR APNYAM 'yf f4Si 111P r, A.1.41 CITY -OC.('7�/.✓ PARCEL SRE/APNR O/ <br /> OWNER'S NAME 1 TGPZPA/ ?20J�'/f �O- ADDRESS R-0- 1'4OX �OOV, S,4,Vf�.��~,V R10NE,492 9±2-- 1pf�- <br /> CONTRACTOR 11 N/ ��I(M ADDRESS f.0- 8OX e �/ <br /> 9( p1 k1 PVI� �-L(CI O PHONE �IJ3� <br /> SUBCONTRACTOR ADDRESS 0/11- / �•/ T/ I UCM PHONE -f165/yvS <br /> TYPE OF WELLPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL.Y J <br /> ❑Nay❑Repair N.P. DEPTH PUMP SET_FT. FIRST WATER LEVEL O <br /> TYPE OF PUMP) <br /> ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ SOIL BORING B <br /> DESTRUCTION: 4�11P,VW4 -2-1NeW W r And <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING O <br /> ❑ DOMESTICIPLUVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEELP C DIA.OF WELL CASING D <br /> ❑ PUBUCRAUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITORING GROUT SEAL PUMPED: 11 Y. [3 N. CONCRETEPEDESTALBYDNLLFR:❑Ys ❑No S <br /> APPROX.DEPTH LOCKING CHESTER BOXISTOVE PIPE S <br /> PROPOSED CONSTRUCTIONIdBWNO METHOD: MUD ROTARY AIR ROTARY AUGEfl CABLE OTHER <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 AN <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOl1AVANG:"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORRAAN'S COMPENSATION LAWS OF CAUFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: -!,CERTIFY THAT IN THE PERMICE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CAUFORNIA.- TH P MUST C M IE IX ADV lS@ FOR ALL REQUIRED INSPECTIONS AT 006146fi3A23. COMPLETE DRAWING AT LOWER AREA PROVIDED. / <br /> sl'I x Title /01' g'd Dns T �O <br /> r'TS O Iv DINT RAM(Dray to Sulal Sulo_"to SO J <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE RECTION. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,AN GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED NCLU DING AND LOCATION OF ALL EXISTING AND DRIVEWAYS, <br /> S. LOCATION OFWELLSO ADJOINING <br /> RADIUSOFONE HUNDRED FIFTY <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,ONVEWAVS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> N <br /> TMW-$ <br /> o �„ <br /> V-4 <br /> 1 mw <br /> MW-4 <br /> si V-6 <br /> n <br /> mw-I <br /> V-1� V 3 _ } Mw S <br /> W <br /> IL <br /> Fwy7 w V-2%Mw-aZ+ <br /> ffAZY>/.v4 _L7/ar <br /> DEPARTMENT USE ONLY <br /> - MPhutbn-AccFteO'BY�_ + J�� - _ - Deta L r Arw <br /> Grout Impaction ey DAte Pump Impectlon By Dete <br /> Dstructipn Impctien By <br /> Dill. <br /> CemmenM: <br /> ACCOUNTING ONLY: AID( FAC# <br /> PE CODES FEE(NPO AMOUNT REMITTED CHECK#MASH RECEIVED BY DATE P IT/SERVICE REQUEST NUMBER INVOICE <br /> 0 330', II•lbYb c>l I o0 <br />