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� APPLICATION FOR WELLIPUMP PERMIT <br /> IN JOAQUIN COUNTY PUBLIC HEALTH SERVIO <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 95201.388 <br /> 12091 468.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FRDNi 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 DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 81-1 11 5,3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC/HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> .YOB ADDRESSIOR fAF-0 ^`"1 2 L CITY <br /> �_l/ � 11 'C <br /> � -�7 PARCEL SIZEIAPNI f <br /> OWNER'S NAME J[ C- C'`�! ADDRESS �''-f l..C. L j r Z kl'o I jNafL t_I C i� PHONE r!' �'] U I <br /> CONTRACTOR- I`' L Lr~r -41 D J'- . c i�{ r • I✓ t,d o r fY,4LICO _PHONE#e-1 <br /> SUBCONTRACTOR J U 4 7 AD11E1A'9?d' /1?9T�LIC 11 'fk PHONE a#` %,1 3 7/ <br /> qm <br /> r■ <br /> TYPE OF WELLIPUMP: NEW WELL ❑ REPLACEMENT WELL MONITORING WELLN ❑ OTHER <br /> ❑ INSTALLATION Q WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# <br /> 13 Now❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> ITYPE Of PUMP) <br /> ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL# SOIL BONNG <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL OPEN BOTTOM DIA.OF WELL EXCAVATION l_ DIA.OF CONDUCTOR CASING D <br /> PDOMESTICIPRIVATE ET <br /> GRAVEL PACKISIZE, TYPE OF CASINGISTEELIPVC ' '� DSA.OF WELL CASINO y D <br /> ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL I SPECIFICATION <br /> ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROIN BRAND NAME Yi.%--L, jt­f�D <br /> MONITORING GROUT SEAL PUMPED: Yes ❑No CONCRETE PEDESTAL BY DRILLER:❑Yr ❑Ne S <br /> APPROX.DEPTH LOCKING CHESTER BOXISTOVE RPE 5 <br /> PROPOSED CONSTRUCTRONIONLUNO METHOD: MUD ROTARYAIR ROTARY AUGER---Y,CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THA'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 WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES N <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FCR WHICH THIS PERMIT IS ISSUED,I GHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.-,-WOO) T CALL 24 MIS IN ADVANCE FOR ALL MEQU1RED INSPECTIONS AT(2081/482-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. J! <br /> Slarxd X r--tti Ttle17/�f'�L / ,/LU7 baro <br /> PLOT PLAN(Draw to Scale}Seale 'to D <br /> 1. 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. EXPANBION OF SEWAGE DISPOSAL SYSTEMS. ('\\ <br /> 3. DIMENSIONED OUTLINFS AND LOCATION OF ALL EXISTING AND PROPOSED U. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT- 3 - <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> -t <br /> DEPARTMENT USE ONLY 1'] <br /> Application Accepted By Date /Z ,Area `/ <br /> Grout Inspecvan By Data �cJ Pump Inspection By ,Date <br /> Destruction Ir pectian Sy_ Data <br /> comment.: <br /> ACCOUNTING ONLY: AID# FACT' <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK*tCAAH RECEIVED OY DATE PERMIT/68 MCE BEQUEST NUMBER INVOICE <br />