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APPLII:ATION F011 WELL(PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> I. <br /> P.O. BOX 388, 3M EAST WEBER AVENUE, STOCKTON, CA 96201 <br /> C I.,(209) 469-3420 + <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 0 <br /> IcampatB in THPIkeh} <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL.THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN r <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1116.3 AND TI4E STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADOREBBIDR APNO CITY tt[,rri PARCEL SIZVAPN!IQ [' .Ap,5; y' <br /> OWNER'S NAME ADDRESS 2•7 j V. PHONE I_ <br /> CONTRACTORADnnERs t'fC36� g{ ecl UCO PHONErZdF-�iS2rS) <br /> OUR CONTRACTOR 1 ADDRESS LICK PHONE! <br /> TYPE OF WELUIPUMP: El NEW NEW WELL ❑ REPLACEMENT WELL MONITORING WELL K ❑ OTHER _ <br /> ❑ INSTALLATION ❑ WELL SYSTEM VtPAIn ❑ CRORS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL R <br /> © <br /> {TYPE OF PUMPL New 13Repelr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> ❑ OUT•OF•SERVICE WELL )❑ GEOPHYSICAL WELL I ❑ SOIL BORING 9 N <br /> Z <br /> IH TENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A � <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.Of WELL EXCAVATION DIA.OF CONDUCTOR CASING p <br /> ❑ DOMESTICMPRIVATE ❑GRAVEL PACKMIZE TYPE OF CARINGISTEEL/PVC DtA.OF WELL CASINO p + <br /> ❑ PUBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT REAL SPECIFICATION rrr'G <br /> ❑ IRRIGATION/AG ❑OTHER GROAT SFAI.INSTALITO BY GROUT BRAND NAME <br /> ❑ MONITORING v GROUT SEAT.PUMPED: ❑Yes [IN. CONCRETE PEDESTAL BY DRILLER:❑Yes [IN. g <br /> APPROX.DEPTHLOCKING CHESTER BOXISTOVE PIPE S <br /> PROPOSED CONSTRUCTIONIDAILUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL RF.DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENRED AOFNT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH I <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 <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOgK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'/COMPENSATION LAWS OF I <br /> CALIFORNIA.' IEA CANT Mt RTC L 24 R t1Ra IN ADVANCE FOR AIL Rit'01UHfD IF48PEClIONO AT[2001 B_1z�, •pM1I.ETE bRAWI AT LOWER AREA PROVIDED. <br /> r ���J(J, J.FE MQ Iq <br /> 8lpned X ".(LS. J' ThFe_��,C"*44..,., Qt�`�'� I 1 ''r/1xi '104.94. Oats <br /> PLOT PLAN[Draw to Scale)Seals "to <br /> I. NAMES Of STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. <. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL BYBTEMS. <br /> R. OFMENSIONEO OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS Of ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY, <br /> 0 c:rN <br /> 1 <br /> fi-)AYME <br /> MAR 12: 19.96: <br /> 'A L 1.i(AcI •LlE'� }-- <br /> "UBLIC HEALTH SE0VICE <br /> NUIvi <br /> 130NMENTAL HEALTH DIVIS1(-)k! t <br /> ::.....:.....:.....:........... <br /> ....:............. <br /> r„e Ys.— ..-_-_�-�-�.=���__�-- _- �- -_ --- - -'D6PARTMtIY i-USF PNtY�� .�.�-. .d.�-�-? `- .�-�-���r=-�--"=•:�1 <br /> Application Accepted By -_ Dote Z Areal y <br /> Grout Impaction By Date henp Inepec[lon By Deta�� <br /> Oeefruetlen Irnpeollon By ' <br /> Deta O k] <br /> Comments: <br /> TING q AIDR FACET <br /> limov <br /> PE CODES F AMOUNT REMITTED HEC% IC all RECEIVED BY DATE PEHMITRSERVICE REQUEST NUMBER INVOICE <br />