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APPLICATION FOR WELLIPUMP PERMIT (_ <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES Jl� <br />ENVIRONMENTAL HEALTH DIVISION <br />7z^ _ 9 � P 0 BOX 388, 446 N. SAN'Z09)68.3420Q 1STOCKTON, CA 96201.388 <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 MADE IN COMPLIANCE WITH SAN <br />JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION, <br />JOB ADDRESS/OR APPNN#� F / DyrC4 & CITY^ Ste' Vv I V 1 Of -4)1( <br />✓ PARCEL SIZE/APNX 2 -79 -3 -73 -? <br />q _ <br />OWNER'S NAME 8rI eS "I D n e /e Si7��'L>° ADDRESS lWt, FirC 5 �1e Pf,w 1 PHONEZLC 7 -7 / —3773-? <br />)—1Gvo-� o t+ L/4I31?-oao 1 <br />CONTRACTOR Gt, (svW A C I ADDRESS 2 1 LIC# p PHONE Q''7 <br />SUB CONTRACTOR S P r I:.t�• Ex �� r L jt L ADDRESS Z7i0 S C.-� (tT1 L0C^'1- LJC# 51Z.24, O PHONE # `�✓ "+ -8 C LZ <br />TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL # ❑ OTHER <br />❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS -CONNECT REPAIR ❑ VAPOR EXTRACTION WELL # ✓ <br />11New 11Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O � tom. <br />(TYPE OF PUMP) "\. <br />11 <br />),DESTRUCTION: -Dtr0 <br />C1OUT-OF-SERVICEWELL 11 GEOPHYSICAL WELL # <br />DA (o wo,. \s Pressu�e (,La-Cli -){� � <br />❑ SOIL BORING <br />ins�cie ?c,,dAka"1 <br />B <br />O <br />� <br />PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE <br />PETiM1T/SERVICE RE EST NUMBER <br />(�(� <br />INTENDED USE <br />TYPE OF WELL <br />CONSTRUCTION SPECIFICATIONS <br />A <br />❑ INDUSTRIAL <br />❑ OPEN BOTTOM <br />DIA. OF WELL EXCAVATION <br />DIA. OF CONDUCTOR CASING <br />D <br />❑ DOMESTIC/PRIVATE <br />❑ GRAVEL PACK/SIZE <br />TYPE OF CASING/STEEUPVC <br />DIA. OF WELL CASING <br />D <br />(� <br />❑ PUBLIC/MUNICIPAL <br />❑ DRIVEN <br />DEPTH OF GROUT SEAL <br />SPECIFICATION <br />R <br />❑ IRRIGATION/AG <br />❑ OTHER <br />GROUT SEAL INSTALLED BY <br />GROUT BRAND NAME <br />E <br />❑ MONITORING <br />GROUT SEAL PUMPED: ❑ Yes ❑ No <br />CONCRETE PEDESTAL BY DRILL FR: ❑ Yee [IN. <br />S <br />APPROX. DEPTH <br />— <br />LOCKING CHESTER BOX/STOVE PIPE_ _ __ <br />S <br />GQGQUU�� <br />PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY <br />AIR ROTARY AUGER <br />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, STATE LAWS, AND RULES AND <br />REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br />THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUB -CONTRACTING SIGNATURE CERTIFIES <br />THE F WING: ' I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CALI 0RNIA.- T APPLICANT M ST LL 24 1 ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12091 4683423. COMPLETE DRAWING AT LOWER AREA PROVID D. / 7 /\� <br />Signed X TIti. ��� a, �� Date p `� <br />SPFS PLOT PLAN (Draw to Scale) SuIe to <br />1. NAMES OF STREETS OR ROADS NEYhEe TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />2. OUTLINE OF THE PROPERTY, GIVIN MENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6. 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 />/ DEPARTMENT USE ONLY <br />Application Accepted By_Nk*� Date <br />Grout Irspection By Date Pump Inspection By Date <br />Destruction Irupection By '' Date I <br />A s. .� n �. . /.r r . A n _ . <br />ACCOUNTING ONLY: <br />AID# 71A.1t <br />® <br />c <br />7'] <br />�` (r <br />PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE <br />PETiM1T/SERVICE RE EST NUMBER <br />(�(� <br />