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APPLICATION FOR WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES }�b W (x -CS WJ — <br />ENVIRONMENTAL HEALTH DIVISION <br />304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br />(209) 468-3420 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED P'v I �.4—u_1� L t_u 1 <br />(CompNu IB Triplkatol <br />APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/On INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WRIT SAN <br />JOAQUIN COUNTY DEVELOPMENT TITLE`+, CHAPTER 9-1115.3 ND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION, <br />JOB ADDRESS/OR APN/ MLU 'L�1, �...Il U F� CITY PARCEL SIZE/APNI <br />OWNEn'S <br />CONTRACTOR <br />SUB <br />TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL <br />❑ INSTALLATION ❑ WELL SYSTEM REPAIR <br />❑ New ❑ Repair H.P. <br />R YPE OF PUMP) <br />� <br />f� 1T ❑ OUT -OF -SERVICE WELL <br />w� <br />DESTRUCTION: • ` t (,n.L4 C�-[aL <br />❑ INDUSTRIAL ❑ OPEN BOTTOM <br />❑ DOMESTIC/PRIVATE ❑ GRAVEL PACK/SIZE <br />❑ PUBLIC/MUNICIPAL ❑ DRIVEN <br />❑ IRRIGATION/AG �OTHERTf <br />❑ MONITORING 4 <br />APPROX. DEPTH C it_ j <br />PROPOSED CONSTRUCTIONIDAILUNO METHOD: MUD ROTARY <br />ADDRESS_ PHONE / <br />_ ADDRESS �� LICI PHONE <br />ADbRESS�L%t' �iDs LICK PHONE <br />❑ MONITORING WELL <br />❑ CROSS -CONNECT REPAIR <br />DEPTH PUMP SET FT. <br />❑ GEOPHYSICAL WELL I. <br />OTHER 1 r 'vq.I'-%i�Tn�f�i�l,l'�y <br />❑ VAPOR EXTRA RON WEL I <br />FIRST WATER LEVEL O <br />❑ SOIL BORING <br />DIA. OF WELL EXCAVATION /� , I DIA. OF CONDUCTOR CASINO <br />TYPE OF CASINO/STEEL/PVC r_ DIA. OF WELL CASING rl <br />DEPTH OF GROUT SEAL SPECIFICATION <br />GROUT SEAL INSTALLED BY a GROUT BRAND NAME <br />GROUT SEAL PUMPED: ❑ Yes }lo CONCRETE PEDESTAL BY DRILLER: ❑ Y. QNo <br />LOCKING CHESTER BOX/87OVE PIPE <br />AIR ROTARY AUGER) CABLE OTHER <br />1 HE9EBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND <br />REOULATIONS 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 IR ISSUED, 1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB -CONTRACTING SIGNATURE CERTIFIES <br />THE ' 1 THAT IN THE PERFORMANCE WORK FOR WHICH THIS PERMIT 18 ISSUED, 1 SHALL SUBJECT WORKMAN'S <br />FOLLOWING: CERTIFY OF THE EMPLOY PERSONS TO COMPENSATION LAWS OF <br />CALIFORNIA.' T PPUCANT MU T C 21 OURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 120014"-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />PE CODES FEE INFO <br />/�J� <br />�I V '�..C% i, 4 — 7 —L <br />CITE KI CASH <br />Btpned X , Title <br />1 Dote 1 L <br />PERMIT/SERVICE REQUEST NUMBER INVOICE <br />PLOT PLAN (Drew to Soak) Seale ' to <br />1. NAMES OF STREETS OR ROADS NEAREST TO On ROUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL BYSTEM On PROPOSED <br />7. OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />Ol J 5-6 <br />3. DIMENSIONED OUTUNFS AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNOnEO FIFTY FT. <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br />Apolkatlen Accepted By <br />Grout Imeeollon By <br />D...vrKuon I,..nMuo.. <br />C Mmmer\ta: �- <br />pk" ' (, <br />DEPARTMENT USE ONLY <br />Pump Inspection By <br />Dale 6 Arse 6SA <br />Date <br />ACCOUNTING ONLY: <br />AIDI <br />FAC! <br />PE CODES FEE INFO <br />AMOUNT REMITTED <br />CITE KI CASH <br />RECEIVED BY <br />DATE <br />PERMIT/SERVICE REQUEST NUMBER INVOICE <br />Ol J 5-6 <br />S,R obiSSg3 <br />Pub. Health Serv. - Enviro. 173 (1/97) �' <br />