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Do�!2il <br />APPLICATION FOR WELLIPUMP PERMIT <br />SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P,O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201368 <br />(209) 466-3420 <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, �C,THAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESSOR APN# 1705 1' • Broadway y, CIS, +�tockton PARCEL SIZE/APN# <br />OWNER'S NAME V'� illiam P & George F. ochuler ADDRESS 1117 Bristol 'Ave, 3tn 402-2398 <br />n' y,,,�,� {,�-�,� PHONE # <br />CONTRACTOR '�7.(�-'L+rL,ln� �xP10+^C1�--7 �l'� ADDRESSA3&S L(,Ileji.-,(Iin.J► -k # SI �' PHONEx r •C� /�� <br />SUB CONTRACTOR ADDRESS UC# PHONE # <br />TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL MONITORING WELL # ❑ OTHER <br />❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS -CONNECT REPAIR Q VAPOR EXTRACTION WELL # :� J <br />❑ New ❑ Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br />O <br />(TYPE OF PUM% <br />❑ OO.UT-O`F-SER'VJIC/E��W%ELiL� ❑ GEOPHYSICAL WELL � ❑ SOIL BORING <br />yet // <br />{!J DESTRUCTION: <br />g <br />FAC# <br />J, <br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br />A Q" <br />❑ INDUSTRIAL ❑ <br />OPEN BOTTOM DIA. OF WELL EXCAVATIONDp4. OF CONDUCTOR CASING <br />O�I <br />11DOMESTIC/PRIVATE 13 GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC A. OF WEL�SASING <br />DZ <br />11PUBLICIMUNICIPAL El DRIVEN DEPTH OF GROUT SEAL PECIFICATKIN <br />g <br />11IRRIGATION/AG ❑ OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME <br />E �• <br />❑ MONITORING GROUT SEAL PUMPED: ❑ Yea ❑ No CONCRETE PEDESTAL BY DRILLER: ❑ Yes ❑ No <br />S C <br />APPROX. DEPTH LOCKING CHESTER BOX/STOVE PIPE <br />g <br />PROPOSED CON STRUCTION/DRILU NO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br />p� <br />I <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 <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: 1 CERTIFY THAT IN TH R MANCE OF THE WO FOR WHICH THIS PERMrT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS <br />OF <br />- <br />CALIFORNIA. T EP ANT TAVST CA 2 8 'ADVANCE FO ALL REQUIRED INSPECTIONS AT i20e1 440-S423. COMPLETE DRAWING AT LOWER AREA PROVIPED.G�� C' / , <br />/1 Owner <br />A, <br />Signed X V L� Title Date <br />PLOT PLAN Oimr to Scab) Sulo 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 />J. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WrTHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br />1 DEPARTMENT USE ONLY r Accepted By <br />Appli <br />i \ / 1;f <br />cetlon Date <br />Grout Ir pectlon By Date Pump Inspection By <br />Destruction Impaction By — '}/�/�J� +{-' R fit• q Date _ <br />Comments: //�' `�'�/ , 1 s- {/ �'i /` ` ; riarw�a� <br />ACCOUNTING ONLY: <br />AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED CHECK#/CASH RECEIVED BY <br />DATE <br />CE REG UMBER INVOICE <br />