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APPLICATION FOR WELL►PUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />RO. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br />(209) 4663420 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED L) o4l (2, (, C, <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 9-1 111�d✓ <br />15..3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. ,1 <br />JOB ADDRESS/OR APN# �y...-1(AA-,,0S— .?14 ( JDy/ 121/clrr LO6 I PARCEL SIZE/APN/_ <br />OWNER'S NAME/�J IK G-`1 i ADDRESS 151 Rmmhbtwt A1( ►�"t 1' A C• QS2q0 PHONE R <br />CONTRACTOR -;5 ( 1[,y�Q�q �nJ ADDRE88_ Z�jS�,,f,Q(�, _NA S -LT Acn LIC ] I`HONE# 5-&7doz <br />RUB CONTRACTOR ADDRESS c! UC/ PI1ONE <br />ff <br />TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL / ❑ OTHER <br />❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS -CONNECT REPAIR ❑ VAPOR EXTRACTION WELL # <br />❑ <br />(TYPE OF PVMPI New 11Repelr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br />/ <br />11 OUT or SERVICE WELL ❑ GEOPHYSICAL WELL # 1 rySOIL BOnINO j B <br />❑ DESTRUCTION: <br />INTENDED USE TYPE OF WELL <br />CONSTRUCTION SPECIFICATIONS- <br />A <br />❑ INDUSTRIAL ❑ OPEN BOTTOM <br />❑ DOMESTIC/PRIVATE ❑ GRAVEL PACK/SIZE <br />DIA. OF WELL EXCAVATION <br />DIA. OF CONDUCTOR CASINO <br />O <br />❑ PUBLIC/MUNICIPAL ❑ DRIVEN <br />TYPE OF CASINO/STEEL/PVC <br />DIA. OF WELL CASINO <br />D <br />^ <br />❑ IRRIGATION/AG ❑ OTHER <br />DEPTH OF GROUT SEAL <br />SPECIFICATION <br />R <br />GROUT SEAL INSTALLED BY <br />GROUT BRAND NAME <br />E <br />❑ MONITORING [� <br />GROUT SEAL PUMPED: ❑ Vee ❑ No <br />CONCRETE PEDESTAL BY DRILLER: ❑ Yee []No <br />5 <br />APPROX. DEPTH (� -�w <br />LOCKING CHESTER BOX/BIOVE PIPE <br />PROPOSED CONS TRUC TTONIDRILLINO METHOD: HUD ROTARY <br />AIR ROTARY AUGFn <br />CABL OTHER <br />1 HE9EBV CERTIFY THAT 1 I4AVE PREPARED THIS APPLICATION AND THAT l HE WORK WILL BE DONE IN ACCORDANCE WITtl N JOAOI, COUNTY ORDINANCES, STATE LAWS, AND RULES AND 10 <br />REGULATIONS OF TNF SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWIV '1 CERTIF , IHAT IN THE PERFORMANCE OF THE WORK FOR WHICH (Z. - <br />T1416 PERMIT IS ISSUED, 1811ALL NOT EMPLOY PERSONS SUBJ O WORKMAN'S- COMPENGA71ON LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB -CONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: 1 CERTIFY THAT IN THE PERFORMA OFYI WORK <br />FOR <br />WHICH THIS PERMIT 18 ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S- COMPENSATION LAWS OF <br />CALIFORNIA." THE AP ANT MUST CALL 24 HO N AD FOR ALL REQUIRED TION11 AT (20111 4011-3427. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />ou bel�aQo6 ��d�tY� <br />Stoned X Title K+� <br />�" _ Det. (..(1:-�-'q J1 <br />PLOT PLAN (D,. to Sale) 8001e to <br />1. NAMES OF STREETS OR ROADS NEAREST 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. <br />7. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED B. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS. AND WALKS. nu na <br />Appllcstlon Accepted <br />O—A Irnpoollon By <br />D-1—tlon Irn'rpecti000n <br />Ce --w & � <br />ACCOUNTING ONLY: I AID# <br />PE CODES FEE INFO AMOUNT REMITTED EI <br />Pub. Health Serv. - Enviro. 173 (3/96) <br />Dote <br />CHECv01:A8H <br />DEPARTMENT USE ONLY <br />M—P Irnpeetten By___ _ <br />FAC# <br />RECEIVED BY <br />D.1e W Arse Cy/2-1- jt --k <br />Uel. <br />DATE <br />PERMITISERVICE REQUEST NUMBER <br />INVOICE <br />