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APPLICATION FOR WELLIPUMP PERMIT �� <br /> r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES13 <br /> ENVIRONMENTAL HEALTH DIVISION0 !c <br /> P 0 BOX 388, 446 N. SAN JOAQUIN STM ��STOCKTON,CA 96201.388 <br /> (209) 468.3420 A& ° <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 described. This application is <br /> made in compliance with San Joaquin County Development Title, Chapter 9-1115.3 and the St rds of San Joaquin County Public Health <br /> Services, Environmental Health Division. i! r n <br /> Job Address/or APN# City ParceL Size/APN# ! �®d <br /> L4 <br /> R <br /> Owner's Name `4� A ress Phone <br /> Contractor P Address 1W /A9 lic# Phone # <br /> Sub Contractor glLL! Address /U Ste_ Lic# a 7 Phone �fl6— <br /> TYPE OF WELL/PUMP: [] NEW WELL [I REPLACEMENT WELL U MONITORING WELL # [I OTHER <br /> 11 DESTRUCTION [I OUT-OF-SERVICE WELL [] GEOPHYSICAL WELL # SOIL BORING O <br /> [] INSTALLATION I] WELL SYSTEM REPAIR [] CROSS-CONNECT REPAIR [] VAPOR EXTRACTION WELL # <br /> [] New [] Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> [I INDUSTRIAL [I OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING <br /> [I DOMESTIC/PRIVATE [7 GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA. OF WELL CASING <br /> [] PUBLIC/MUNICIPAL [I DRIVEN �` DEPTH OF GROUT SEAL SPECIFICATION <br /> [I IRRIGATION/AG (d OTHER !v GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> [] MONITORING n , GROUT SEAL PUMPED: [I Yes [] No CONCRETE PEDESTAL BY DRILLER: [I Yes ❑ No <br /> APPROX.DEPTH C� / " 1� LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTRUCTIONIORILLING 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. Home owner or licensed agent's signature certifies the following: 11I <br /> certify that in the performance of the work for which this permit is issued, I shalt not employ persons subject to WORKMAN'S COMPENSATION <br /> Laws of California.11 Contractor's hiring or sub-contracting signature certifies the following: 11 I certify that in the performance <br /> of the work for which this permit is issued, I shalt emptoy persons subject to WORKMAN'S COMPENSATION Laws of California." THE APPLICANT <br /> MUST CALL 24 HOURS IN ADVWE FOR ALL REQUIRED INSPECTIONS AT(209) -3423. Complete drawing at Lower area provided. <br /> Signed X Title �` ' Date <br /> PLOT PLAN (Draw to Scale) Scale 1/ to <br /> 1. Names of streets or roads nearest to or bounding the property. 4. Location of house sewage disposal system or <br /> 2. Outline of the property, giving dimensions and North direction. proposed expansion of sewage disposat systems. <br /> 3. Dimensioned outlines and location of alt 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 rip <br /> P AN ®AQ <br /> rV AL N g Rms/ <br /> FL: <br /> ELL <br /> D THENT USE ONLY 1 <br /> Apptication Accepted By G". Date / Area <br /> zs <br /> Grout inspection"dy Date Pump Inspection By Date <br /> Destruction\1jrpection 8y Date Comments: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK11CASH RECEIVED BY DATE PERMITISERVICE REOUEST NUMBER INVOICE <br />