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APPLICATION FOR WELLIPUMP PERMIT <br />SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES D;vtIvEg <br />ENVIRONMENTAL HEALTH DIVISION <br />P 0 BOX 388, 446 N. SAN JOAOUIN ST., STOCKTON, CA 96201.388 M A Y 1, 3 1995 <br />(209) 468.3420 <br />NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH <br />(Complete in Triplicate) PERMIT/SERVICE" <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 <br />9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC <br />HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR APN# l� 7S� /�Y/w�`� CITY 7/ /�y 'D \ PARCEL SIZE/APNN I t'`�'G. <br />OWNER'S NAME <br />AA /V� /�, (��JJ ADDRESS /.2 757V 0 • S S/�v KJ �J PHONE # <br />CONTRACTOR�{IX/.!746r% [�"yG�✓!/�Q61^/�ftErts%AZ�/ /�L_ ADDRESS /40-Z W - ifitAJZ-A=lucX PHONEM-6 G-A�f <br />J sracCrcw Ga 75.2a7 L-7 9�6 <br />SUB CONTRACTOR �U�/K/•t 4 f%Ld� j7& ADDRESS PHONE # <br />TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL X ❑ OTHER <br />❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS -CONNECT REPAIR ❑ VAPOR EXTRACTION WELL # J <br />❑ New ❑ Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br />(TYPE OF PUMP) <br />jj ❑ OUT -OF -SERVICE WELL 1 ❑ GEOPHYSICAL WELL X 13 SOIL BORING 8 <br />DESTRUCTION: C�/ Z ��!�' wcu'6 r c2 / 49G//� <br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br />❑ INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING O <br />❑ DOMESTIC/PRIVATE bo GRAVEL PACK/SIZE TYPE OF CASING/STEEUPVC DIA. OF WELL CASING D <br />❑ PUBLIC/MUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br />�❑(J�RIGATION/AG ❑ OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br />K MONITORING GROUT SEAL PUMPED: ❑ Ya ❑ No CONCRETE PEDESTAL BY DRILLER: ❑ Yea 13N. S <br />APPROX. DEPTH p25 LOCKING CHESTER BOX/STOVE PIPE $._ <br />PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 9D <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 FOLLOWING: " 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 />CALIFORNIA." EAP CANT UST CAL24 URS IN ADVANCE FOR ALL REQUIRED ECTIONS AT (2j099)) 4583423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Signed X Tltle�v 'V �1 Date �J C. <br />PLOT PLAN (Draw to Scale) Scale " to <br />1. NAMES OF STREETS OR ROADS NEA TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />2. OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. S <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 />S�� "PL/1-� .:....... ...:.... <br />.. .. ............... <br />..:.. ..:.. .. ..... ..... ..... ..... ... <br />DEPARTMENT USE ONLY <br />4�4 <br />Application Accepted By Date L Area <br />Grout Inspection By Date Pump Inspection By Date <br />Destruction Inspection By Dae <br />Comments: J <br />C ,�' / <br />ACCOUNTING ONLY: <br />AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED CHEC CASH RECEIVED BY DATE <br />PERMIT/SERVICE REQUEST NUMBER <br />INVOICE <br />