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/ APPLICATION FOR WELLIPUMP PERMIT <br />( SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES .' <br />ENVIRONMENTAL HEALTH DIVISION �� <br />P 0 BOX as, 445 N. SAN JOAOUIN ST, STOCXTON, CA 95201.391 <br />(2091 488-3420 / \ <br />809-AEFUNOABIE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />IG.al.es V inifliestal <br />Application is here by made co the San Joaquin County for apermit to construct and1or Install the wrk described. This application Is <br />made In coaplianca with San Joaquin Canty Development Title, Chapter 9-1115.3 and the Standards, of San Joaquin County Ptotic Health <br />Services, Environaen[al Health Division- <br />. i E. ^1 <br />Job Address/or APNM,. / ,��"r-'/^r `��' / �C�If[y J/tJ�'�i'� parol Size/RPM/ �/ <br />Owner's Nus 0t 0-t?a+ 1i4/Xy0 �IKC in 1kVt"AddressS14 /v F le n ' /� J Phone 1 ��-tJ 7 6✓ '�Y3 Y/3� <br />Cener r /V I /tel( \v r0 %S V Address 46),76 'e" D d /� Rzr4 d"! l� / Phone <br />.&.b Concracior L1zk1Af r y1'17�2L1 Address go i �a ,-Y,GA�f cars c! T /6 �� Phone ! 2/6 3 72 — y i 3 <br />TYPE OF YELLipump: U NEW WELL <br />U DESTRUCTION <br />U INSTALLATION <br />U New U Repelr <br />(TYPE of PUMP) <br />❑ REPLACEMENT WELL <br />U CUT -OF -SERVICE WELL <br />❑ WELL SYSTEM REPAIR <br />N.P. <br />U MONITORING -WELL 1 ' a <br />U GEOPHYSICAL WELL 1 <br />❑ CROSS -CONNECT REPAIR <br />DEPTH PUMP SET FT. <br />❑ OTHER / <br />X SOIL BORING a <br />(I VAPOR EXTRACTION wrLL 1_ <br />FIRST WATER LEVEL <br />INTENDED USE TYPE OF WELL CONSTRUCTION IPECIFICATIONS <br />_V- INDUSTRIAL U OPEN BOTTOM DIA. Of WELL EXCAVATION - JE' "FLCOkDUCTOR CASING <br />U DOMESTIC/PRIVATE U GRAVEL PACX/SIZ_e TYPE Of CASING/STEEL/PVC ''I LA. OF WELL CASING <br />(I PUBLIC/MIIMICIPAL U DRIVEN 1 DEPTH Of GRUT OSEA, '1 to 1`hi- u 4"ECATION <br />U IRRIGATIWAG OTHER `V GROUT )!EAL INSTALLED BY. t M f I� ,g1�AN0 NAME <br />U MONITORING tl GROUT SEAL PUMPED: U yes U N CR LT'E PEDESTAL BY DRILLER: U Yes U No <br />Oajlk,� CHESTEA SOX/STOVE PIPE.1 <br />APPROX. DEPTH <br />PROPOSED CONNSSTRUCTION10RI111Y0 METHOD: ROTARY AIR <br />ROTTA/R��— AUGER = CABLE_ OTHER_ <br />!x+ / ! ✓yam < U / C L1 t [ICY/ `L�d c'r'JS �� Oi Q �% J'z�_iKn�vT C.� l b •C J�t�/ <br />I hereby certify Eh& Wt have prepared mis application and that the wrk ill M done in�accorwnce with San JoagJin County Ordirtarcas, <br />State Laws, and Rut** and Regulations of the San Joaquin County. Nor ormr or licensed agenc'S signature certifies the follawin0: '1 <br />certify that in the performance of the roti[ for which this permit is issued, l shall not employ persons Subject to WORKMAN'S CCMPENSATION <br />Laws of California." Contractor's hiring or sub -contracting siWscurs certifies Che following: N I certify that in the performance <br />of Ino work for which chis permit is isaad, I Shall eaploy persons subject to WORKMAN'S COMPENSATION Laws of California." THEAPPUCANT <br />MUST CALL Il HOURS IN ADVANCE FOR ALL RE31mED INSPECTIONS AT (212#14468-1421. Complete drawing at lower area provided. <br />Signed X T i t l e F.t Date <br />PLOT PLAN (Draw to Scale) Scale to <br />1. Homos of streets or roads nearest to or bounding the property. A. Location of house sewage disposal system or <br />2. Outline of the property, giving dimensions end North direction. proposed expansion of Sewage disposal system. <br />3. Oimensionad outlines and location of sit existing and proposed S. Location of wells within radius of 150 ft. on <br />structures. Including covered area uxh as patios, driveways, the property or adjoining property. <br />6, OEPARTY.. T USE ONLY <br />1f' l I <br />Appl icstfon Accepted 8y1 '(� CI `e I%�' l-'� i. l•' �./` I <br />Dote Are■ <br />Grout Inspection By Oats Ptmp Inscxction By <br />Destruction Inspection By Data Coinents: <br />Dace <br />ACCOUNTINU ONLY: <br />AIDN <br />FACE <br />PE CODES FEE INFO <br />AMOUNT UWTT12 <br />CHLCXJICASH REC13VIO BY DAT€ <br />I PEAYITISElVICE REQUEST NUMBER INVOICE <br />3 <br />t> 08.3-3 �! <br />I <br />I <br />