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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERV <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 446 N. SAN JOAOUIN ST., STOCKTON, CA 95201388 <br /> (209) 4683420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete is Triplicats) <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 Standards of San Joaquin County Public Health <br /> Services, Environmental Health Division. C ( <br /> Job Address/or APN# R5 ,18 Mak-&T ST City JTDC.k-1N^ Parcel Size/APN# ,,/ ,/ <br /> Owner's Name RO � Address I>OK 2.,pS51-"j9SZo / Phone # 831 <br /> / <br /> Contractor ` 1'00(A�hd 2Q/rO Address 11 Lic# Phone # <br /> Sub Contractor ZpPT c S L <br /> Address 28L , 01y✓T-r'C STQJ Lic# 5/2-L4e Phone # 4&5`9712- <br /> TYPE <br /> &5`9)lZTYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL A MONITORING WELL # Ila ❑ OTHER <br /> [I DESTRUCTION [I OUT-OF-SERVICE WELL [I GEOPHYSICAL WELL # ❑ SOIL BORING <br /> ❑ INSTALLATION [I WELL SYSTEM REPAIR [I CROSSCONNECT REPAIR [I VAPOR EXTRACTION WELL # <br /> [I New [I Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS it <br /> p <br /> INDUSTRIAL [I OPEN BOTTOM DIA. OF WELL EXCAVATION <br /> [IS <br /> DIA. OF CONDUCTOR CASING d <br /> [I DOMESTIC/PRIVATE X GRAVEL PACK/SIZE_ TYPE OF CASING/STEEL/PVC If U�- DIA. OF WELL CASING 2/1 RUG <br /> [I PUBLIC/MUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL SD I SPECIFICATION SC,4 SSD <br /> IRRIGATION/AG [I OTHER GROUT SEAL INSTALLED BY Slat] GROUT BRAND NAME Mt 9, F]d ntc <br /> 'MONITORINGGROUT SEAL PUMPED: [I Yes [I No CONCRETE PEDESTAL BY DRILLER: [I Yes [I No <br /> APPROX. DEPTH -T 3 LOCKING CHESTER BOX/STOVE�/P)IPE <br /> PROPOSED CONSTRUCTIONIORILLING METHOD: MUD ROTARY_ AIR ROTARY�AOGER il; CABLE_ OTHER_ <br /> I hereby certify that I have prepared this application and that the work wit'l''t 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: "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 California." Contractor's hiring or sub-contracting signature certifies the following: " I certify that in the performance <br /> of the work for which this permit is issued, I shaLL employ persons subject to WORKMAN'S COMPENSATION Laws of California." THEAPPLICANT <br /> MUST C 24 H RS IN ADVANCE FOR All RED IRED INSPECTIONS AT (209)4683423. Complete drawing at Lower area provided. <br /> Signed X Title &-4� Dateyzso,}— <br /> PLOT PLAN (Draw to Scale) Scale It 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 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 /> DEPARTMENT USE ONLY _ <br /> Application Accepted Byqt •`V`1%t �, " I I�U \ Date L4 I q Are 1 <br /> Grout Inspection By Date Pump Inspection By Date <br /> Destruction Inspection By Date Comments: �h7 /'� <br /> ACCOUNTING ONLY: AID# FAC# 5so I <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#JCASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br />