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APPLICATION FOR WELLIPUMP PERMIT <br /> ®r ,,,.�•• �e ae1 <br /> SAN JOAQUIN COU ,� mac* <br /> PUBLIC HEALTH SERVICES /, <br /> ENVIRONMENTAL HEALTH DIVISION , N 3 W65r <br /> P 0 BOX 388, 445 N. SAN JOAQUIN ST„ STOCKTON,CA 86201.388 <br /> ® (209) 468.3420 c <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) <br /> Apptication is here by made to the San Joaquin County for a permit to construct and/or install the work described. This application is <br /> made in compliance with San Joaquin County DeveLopment Title, Chapter 4-1115.3a the Standards of San Joaquin County Pubtic Health <br /> Services, Environmental Health D'vi <br /> Job Address/orrAPN# LLST/® 14 7 <br /> ® City J —, Parcel Size/APN# / �'A ® 0� <br /> Owner's Name 51- GA�-TVAI Address Cil= L 1 gac eracV Phone #� `�) '73-74 <br /> ContractorL eP�Ae �'- Address /410 Lic# Phone #�L 11-43-2,9k , <br /> Sub Contractor f� 7a4i&-A 6 Address 1645- 5j Licit 04%97 Phone #'4/-)✓ <br /> TYPE OF WELL/PUMP: [l NEW WELL [l REPLACEMENT WELL [l MONITORING WELL # OTHER <br /> [l DESTRUCTION [I OUT-OF-SERVICE WELL [] GEOPHYSICAL WELL # SOIL BORING <br /> [l INSTALLATION [] WELL SYSTEM REPAIR [l CROSS-CONNECT REPAIR [l VAPOR EXTRACTION WELL # <br /> [l New U Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> INDUSTRIAL [I OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING <br /> [I DOMESTIC/PRIVATE (I GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA. OF WELL CASING <br /> [l PUBLIC/MUNICIPAL [l DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> El IRRIGATION/AG OTHER NIA GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> [l MONITORING GROUT SEAL PUMPED: [l Yes ❑ No CONCRETE PEDESTAL BY DRILLER: D Yes 0 No <br /> APPROX.DEPTH E30 — 1-70' LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTRUCTIONIDRILLING METHOD: MUD ROTARY_ AIR ROTARY AUGER 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, <br /> State Laws, and Rules and Regulations of the San Joaquin County. Hare owner or licensed agent's signature certifies the following: "I <br /> certify that in the performance of the work for which this permit is issued, I shall not employ persons subject to WORKMAN'S COMPENSATION <br /> Laws of Catifornia.10 Contractor's hiring or sub-contracting signature certifies the following: t1 I certify that in the performance <br /> of the work for which this permit is issued, I shalt employ persons subject to WORKMAN'S COMPENSATION Laws of Catifornia.t1 THE APPLICANT <br /> MUST CALL 24 HOURS IN ADVANCE FOR ALL REGUIRED INSPECTIONS AT(209)4MM3. Comptete drawing at lower area provided. <br /> Signed X Titte / o6 isl— Date �r <br /> PLOT PLAN (Draw to Scale) Scale " to <br /> 1. Names of streets or roads nearest to or bounding the property. 4. Location of house sewage disposai system or <br /> 2. outline of the property, giving dimensions and North direction. proposed expansion of sewage disposal systems. <br /> 3. Dimensioned outlines and location of all existing and proposed 5. Location of wells within radius of 150 ft. on <br /> structures, including covered areas such as patios, driveways, the property or adjoining property. <br /> and walks. <br /> I AA <br /> A PAYMENT <br /> P1 Buc HEAJTH S RVIC ES <br /> �� <br /> TARTMENT <br /> USE ONLY <br /> Application Accepted By Date Area <br /> rr-it Inspection gy. � � unterump inspection By Date <br /> Destruction\ljrpectfon By Date Comments: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK SH RECEIVED BY DATE PERMITiSERViCE REQUEST RUMBER INVOICE <br />