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APPLICATION FOR WILL)PUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P.O. BOX 3K 304 EAST WEBER AVENUE, STOCKTON, CA 95201-388 <br />(209) 468.3420 <br />❑�IRRIGATIONIAG ❑ OTHER GROUT SEAL INSTALLED BY✓�` (l'�K GROUT BRAND NAME E <br />IJ <br />CJ MONITORING p� n GROUT SEAL PUMPED: Y - LJ No CONCRETE PEDESTAL B BILLER: ❑ Y. ❑ e S <br />APPROX. DEPT" LOCKING CHESTER BOX/STOVE PIPE _ S <br />PROPOSED CONSTAUCTION/DAILLINO METHOD: MUD ROTARY Ain ROTARY AUGFF/ <br />CABU <br />1 f1EREBV CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND T14AT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUL _ COUNTY OnDINA E� S, STATE LAWS. AND ILES AND <br />REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFOR-QP_T11E- W FOR WHICH <br />THIS PERMIT IS ISSUED, 1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB -CONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: ' 1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR( FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CALIFORNIA.' THE APPLICANT <br />MUST CALL 224 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT (2091490-3423. C <br />209111490-34423..0 pO�MPLETE DRAWING �A7T LOWER AREA PROVIDED. <br />Stpned X - -v — \./ t W V � �� Title� �`i� l S I v V � Cll �✓1� S� / I - <br />G I Dete �: <br />�t'eiU �- �•'i LL'PY-' v <br />PLOT PLAN (Draw to SoNel Scel. ' to <br />1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED <br />2. OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WHT4IN RADIUS OF ONE HUNDRED FIFTY FT. <br />STRUCTUnES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. ON TIM MOM— nn en Imuran eo.,-- <br />Applicatlon Accepted By _. <br />O—A (rnpecllen By <br />Ooet—tlon Irnpxllo. By <br />DEPARTMENT USE ONLY <br />bet. II'T1 P.nnp lnepeellen By_ <br />net <br />Dole <br />ACCOUN UNG ONLY: <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />- - - - <br />FACd <br />(Compute in Triplicate) <br />APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/On INSTALL THE WORK DESCRIBED. THIS APMICATION IS MADE IN COMPLIANCE <br />W1711 SAN <br />JOAOIIIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/ORR-�APPN/��') fj �q <br />q� CITY_8AI2(--cl&C, PARCEL SIZE/APN#Q' &I AK OSS-3tU-(( <br />OWNEn-S NAME:] V 2T�RF IA �{pI�U tS�I�� <br />\ <br />�911ci6, F �Ql1Z t / ADDRESS LP110NE R �Zli(�� (�j %1 <br />CONTMCTOR_\LQ <br />ADDRESS c!�SqZpO <br />PHONE/f5(0�Q <br />SUB CONTRACTOR <br />ADDRESS LIC/ PHONE <br />TYPE OF WELL/PUMP: ❑ NEW WELL <br />❑ nEPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER <br />❑ INSTALLATION <br />❑ WELL SYStEM REPAIR ❑ CnOSS-CONNECT REPAIR ❑ VAPOR <br />❑ 11 <br />EXTRACTION WELL / <br />New RRepelr <br />(TYPE OF PUMPI <br />H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br />�� <br />❑ out -or SERVICE WFLL ❑ OFOPHYSICAL WELL I 13 SOIL BORING <br />❑ DESTRUCTION: <br />_ R <br />INTENDED USE TYPE OF WELL <br />CONSTRUCTION SPECIFICATIONS I n <br />❑ INDUSTRIAL ❑ OPEN BOTTOM <br />1 <br />DIA. OF WELL EXCAVATION I . DIA. OF CONDUCTOR <br />❑ DOMEStICIMIVAtE ❑ <br />CASING p <br />GRAVEL PACK/SIZE <br />❑ PVBLIC/MUNICIPAL 1j DRIVEN <br />TYPE OF CASING/STFFL/PVC ¢ DIA. OF WELL CASINO b <br />DEPTH OF GROUT SEAL C)� SPECIFICATION R <br />❑�IRRIGATIONIAG ❑ OTHER GROUT SEAL INSTALLED BY✓�` (l'�K GROUT BRAND NAME E <br />IJ <br />CJ MONITORING p� n GROUT SEAL PUMPED: Y - LJ No CONCRETE PEDESTAL B BILLER: ❑ Y. ❑ e S <br />APPROX. DEPT" LOCKING CHESTER BOX/STOVE PIPE _ S <br />PROPOSED CONSTAUCTION/DAILLINO METHOD: MUD ROTARY Ain ROTARY AUGFF/ <br />CABU <br />1 f1EREBV CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND T14AT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUL _ COUNTY OnDINA E� S, STATE LAWS. AND ILES AND <br />REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFOR-QP_T11E- W FOR WHICH <br />THIS PERMIT IS ISSUED, 1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB -CONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: ' 1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR( FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CALIFORNIA.' THE APPLICANT <br />MUST CALL 224 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT (2091490-3423. C <br />209111490-34423..0 pO�MPLETE DRAWING �A7T LOWER AREA PROVIDED. <br />Stpned X - -v — \./ t W V � �� Title� �`i� l S I v V � Cll �✓1� S� / I - <br />G I Dete �: <br />�t'eiU �- �•'i LL'PY-' v <br />PLOT PLAN (Draw to SoNel Scel. ' to <br />1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED <br />2. OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WHT4IN RADIUS OF ONE HUNDRED FIFTY FT. <br />STRUCTUnES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. ON TIM MOM— nn en Imuran eo.,-- <br />Applicatlon Accepted By _. <br />O—A (rnpecllen By <br />Ooet—tlon Irnpxllo. By <br />DEPARTMENT USE ONLY <br />bet. II'T1 P.nnp lnepeellen By_ <br />net <br />Dole <br />ACCOUN UNG ONLY: <br />AIDI <br />- - - - <br />FACd <br />. 144jE;11 • v V To <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK/!CASH <br />1 RECEIVED BY <br />DATE <br />PErIMITISEAVICE REQUEST NUMBER <br />INVOICE <br />Pub. Heal h Serv. - Enviro. 173 (3/96) � / �J /� �1 � f <br />AI 7 <br />