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APPLICATION FOR WELLIPUMP PERMI' <br /> -SAN JOAQUIN COUNTY PUBLIC HEALTH SERv,LtES <br /> ENVIRONMENTAL HEALTH 01VISION <br /> P.O,BOX 988,304 EAST WEBER AVENUE,STOCKTON,CA 95201388 <br /> (209)488.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM BATE ISSUED <br /> ICBmplet4 In Triplkat4l <br /> APPLICATION 10 HERE BY MADE TO THE CAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH SU <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAIrER H•1115.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESWOR APHO Z'fOPI E. t4.;_ SA- e F sl� ,. CITY '-fyeJZ4 PARCEL&2EIAPN/ <br /> OWNW4 NAME ww"I''1Gn rr"G4- ADDRESS PC)' 8o>G PHONE/ <br /> CONTRACTOR -pact•-c. G,aQ Z.,C. ••'�"'IU <br /> I <br /> - ADDRESS Ir3�5 �Un/.(C..GoI� C.:rrJey tICRG 6260 PHONE/C416J 658•LJSD <br /> /� Q.e.n . G,rd.1. fr gST.,c <br /> SUBCOMMCTOR I-):kci. u Qtm;;:5 E.nyirwirn¢n•Fel ADDRESS_ P•O.6ox 2231 UCEG57 69Lb1? PHONE I(9U6)62•9551 <br /> rh Cc•4dg r 457'1'1 <br /> TYPE OF WELLNUMP. ❑NEW WELL ❑REPLACEMENT WELL ❑MONTrORING WELL f ❑OTHER <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL S <br /> ❑ <br /> STYPE OF PUMP) N—❑R.Wr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> ❑OUT-0F-SERVICE WELL ❑GEOPHYSICAL WELL A, SOIL BORING , <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ❑INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO I <br /> ❑DOMEST/C/mVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/BTEEUPVC DIA.OF WELL CASINO <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> ❑IMOATK)NIAO ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME 1 <br /> MONROPINO GROUT SEAL PUMPED:❑Y« ❑Ne CONCRETE PEDESTAL BY DRILLER:❑Y.. ❑N. <br /> APPROX.DEPTH MNK 0C LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTRUCTIO WN METHOD: MUD ROTARY AIR ROTARY F{AUGE� CABLE OTHER <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL Be DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AI <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AOENT•0 SIGNATURE CERTIFIES THE FOLLOWING:•1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR VMI, <br /> THIS PERMIT IS ISSUED,1 WALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.-CONTRACTOR'S HIRING OR SUBCONTAACTINO SIGNATURE CERTIFI <br /> THE FOCA UFOIINIA.• HB A%/1J�CEL�R/TAI//F/Y�MUST CALL 24 HOURS IN ADVANCE POR ALL REQUIRED INSPECTIONSS AT 1"014".34THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED,I SHALL 22.COMPLETE DRAWING AT LOWER AREA PR/OOVIDE(D..PERSONS SUBJECT TO WORKMAN'S RATION LAWS <br /> sto-d% V'J,!- ✓// TItl. G. -^^�1'�P Sl D.b I�Z L rq7 <br /> 1 PLOT PUN ID­Lo SW.)Sc*o •to <br /> 1.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2.OUTUNE 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 /> I <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> S <br /> i <br /> I <br /> i <br /> i <br /> .... <br /> f . <br /> DEPARTMENT USE ONLY <br /> ADDllo.tlon A.e.Pt.d BY /j/l/J`•'' D.I. /Vw <br /> O...1--d-By D.t. Ptmp lmp.tlon By <br /> D.t. <br /> I <br /> ow—t6'1--ti-By D.t. <br /> Comm.ntr <br /> ACCOUNTINQ ONLY: AIDI FACJ <br /> PE CODES PQ INFO AMOUNT REMITTED CHECK//CASH R[CBVEO■Y GATE PEAPA/SERVICE REQUEST NUMBER INVOICE <br />