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APPLICATION FOR WELLIPUMP PERMIT' <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SEgS <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201 M <br /> (70e) 4$8.3420 <br /> NOM-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> {Complete IB Tr <br /> APPLICATION f8 HERE BY M THE 6 A PERMIT 7tl C ANb'Op INSTALL THE WOW DESCRIBED.THIS APPLICATION IB IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVE PMENT TITLE,C AFTER 9-1 115. NOT B OF SAN JOAQUIN COIL��((11YY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH VISION. <br /> JOB ADDRESWOR PN+r CITY 'PQQ PARCEL 81ZE/APN1? <br /> OWNER'S NAME t I ADDRESS PHONE/ <br /> CONTRACTOR ADDRESS `� D LICI PHONE ✓ '�/� <br /> BUB CONTRACTOR ADDRESS O✓ L1Cr�Z04CY PHONE s3 <br /> TYPE OF WELL/PUMP; ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONrTORING WELL R ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR © VAPOR EXTRACTION WELL/ J <br /> ❑New❑Repelr N.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> (TYPE OF PUMP) <br /> ❑ OUT-0F-SERVICE WELL GEOPHYSICAL WELL Ir ❑ SOIL BORING B <br /> ry�f r! <br /> DESTRUCTION:C�:'V <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 11 A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D <br /> ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINGI8TEELIPVC� V DIA.OF WELL CASINO Z f D <br /> ❑ PUSUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITORING GROUT SEAL PUMPED: ❑Y. ❑No CONCRETE PEDESTAL BY DRILLER:❑Yw [IN. S <br /> APPROX.DEIFTH LOCKING CHESTER BOXIBTOVE PIPE S <br /> PROPOSED CONSTRUCTTONIDRILLINO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HE9EBY 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 COU HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT 16 ISSUED,1 SHALL NOT EMPL 'SONS SUBJECT TO WORKMAN'{COMPENSATION LAWS OF CAUFORNIA,- CONTRACTOR'S HIRING OR BU"ONTRACTWO SIGNATURE CERTIFIES <br /> THE FOLLOYA -I CERTIFY THAT IN THY RFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIUmnueTr <br /> 4URf 1 DVANCE F 2 <br /> OR ALL REQUIRED IN TIQNS�ATIW <br /> ( 6 1 4SSa42S. COMPLETE DRAWING AT LOWER AREA PROVF QED. <br /> Signed X Tltla, �I:V D■te <br /> PLOT MAN(brew to Scala)Sgsle 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING 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 OVTUNF,S AND LOCATION OF ALL EXISTING AND PROPOSED 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE P14OPERTY OR ADJOINING PROPERTY, <br /> t <br /> DEPARTMENT USE ONLY <br /> APpIIo■1Fon Accepted By <br /> —3vL—R&&L D■te ArOd <br /> Grout Inspection By <br /> Date Pump Ins Dien By <br /> Geta <br /> Doslructlon Inspection BY �S T,, , <br /> +v Date <br /> Comments: ILC21 / <br /> lAn 1 . <br /> ACCOUNTING ONLY: AID/ FACT <br /> PE CODES EE INFO AMOUNT REMITTED CHECKI/CMH RECEIVED BY DATE <br /> PF7N T180MCE REQUEST NUMBER INVOICE <br /> 50c S �i <br />