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APPLICATION FOR WELLIPUMP PERMIT <br />SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 95201.388 <br />(2091 4883420 <br />NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Caatplata In Tripileete) <br />Application is here by made to the San Joaquin County for a permit to construct and/or install the work described. This appiication is <br />made in coaptiance with San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br />Services, Environmental Health Division n <br />Job Address/or APN# CP �5'JC 't"a—✓ V1 " G A f r City 57 CcPerceL Site/APNA_ <br />Owner's Name �+ r ( --/� ( r7o1� Address � - — 4_ Phone it <br />Contractor,�,L .L� r(d ,) ��l. C— AddressQ V L c _, c- k�� Licp� -/;Or Phone M� <br />Sub Contractor Address Lic# Phone # <br />TYPE OF WELL/PUMP: (] NEW WELL <br />(I REPLACEMENT WELL <br />[] MONITORING WELL # <br />[I OTHER <br />U DES(RUCTION <br />[1 OUT -Of -SERVICE WELL <br />❑ GEOPHYSICAL WELL # <br />[1 SOIL BORING <br />INSTALLATION <br />New �•'Repair <br />❑ WELL SYSTEM REPAIR <br />X.P. <br />❑ CROSS -CONNECT REPAIR <br />DEPTH PUMP SET_V FT- <br />C VAPOR EXTRACTION WELL # <br />FIRST WATER LEVEL 0 l <br />(TYPE- -OF PUMP) <br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br />INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING <br />�(( DOMESTIC/PRIVATE (] GRAVEL PACK/SIZE.— TYPE OF CASING/STEEL/PVc DIA. OF WELL CASING <br />[] PUBLIC/MUNICIPAL N DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br />(] IRRIGATION/AG [] OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME <br />[] MONITORING GROUT SEAL PUMPED: [] Yes [] No CONCRETE PEDESTAL BY DRILLER: [I Yes [] No <br />APPROX. DEPTH O" D LOCKING CHESTER BOX/STOVE PIPE_ <br />PROPOSED CO NSTRUCTION[DRI L LINO METHOD: MILD ROTARY_ AIR ROTARY_ AUGER_ CAP,LE! OTHER_ <br />I hereby certify that I have prepared this applicat for end 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: "] <br />certify that in the performance of the work for which this permit is issued, ! shall not employ persons subject to WORKMAN'S COMPENSATION i <br />Laws of California." Contractor's hiring or sub -contracting signature certifies the following: " 1 certify that in the perfornance .� <br />of the work for which this permit is issued, I shall employ persons subject to WORKMAN'S COMPENSATION Laws of California." TNF APPLICANT ._ <br />MUST CALL 24 HOURS IN ADVANCE FOR ALL REOUTAED INSPECTI NS AT (2111) 466.3423. Complete drawing at Lower area provided. <br />Signed X title_! l�T Date //6 <br />PLOT PLAN (Draw to Scale) Scale to n <br />1. Names of streets or roads nearest to or bounding the proper' -y. 4. Location of house sewage disposal system or C <br />2. Outline of the property, giving dimensions and North direction. proposed expansion of sewage disposal systems. <br />11 <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 r <br />Application Accepted By Date ( L t Area <br />Grout Inspection By Date Pump Inspection 6y _�`—j ,��`� " ' —� <br />Date /f.ld <br />Destruction lnspection By <br />ACCOUNTING ONLY: I AID# <br />Date Cements <br />FAC# <br />PE CODES FEE INFO AMOUNT REMITTED HECK ASH RECEIVED BY DATE PERNITISERVICE REOUEST NUMBER INVOICE�� <br />O x o fly 0 <br />