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APPLICATIsI FOR WELL)PUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION PAYM, <br />P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 RECF <br />(209) 466.3420 - <br />NON-REFUNDABLE PERMIT 2i. AL <br />APPLICATION IS HERE BY MADE TO THE SAN JOAGUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPUCAT1bN IS'MADE IN COMPuANCE-WITH.SAN <br />JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-111 5.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. ENVIRONMENTAL HEALTH DIVISION. L <br />JOB ADDRESSOR APNI L %U S ,L - 6 /{' - ,' CITY PARCEL 8IZE/APNI ' <br />1 <br />OWNER'S NAME ir�XKEi J C Lti,VL,I/�UJ� U' J ADDRESSCi".1 gd . tPHONE I SIO�s�-!:✓p ' fS%7L <br />T� <br />CONTRACTOR `7 - G ADDRESS UCI yc".z(„-� PHONE I `71L)F,53 'L.'f <br />SUB CONTRACTOR ADDRESS LOC/ PHONE t <br />TYPE OF WELLJPUMP: [3 NEW WELL REPLACEMENT WELL ❑ MONITORING WELLf ❑ OTHER <br />❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS -CONNECT REPAIR VAPOR EXTRACTION WELL I <br />[3New11Rww, H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL D <br />(TYKE OF P'JI.lPI <br />❑ DESTRUCTION: <br />❑ OUT-OFSERVICE WELL ❑ GEOPHYSICAL WELLI ❑ BOIL BORING <br />A <br />Dl lam, <br />R �> <br />E S <br />--4 <br />s <br />s n <br />V <br />INTENDED USE <br />TYPE OF WELL <br />CONSTRUCTION SPECIFICATIONS <br />I jCHECK#CASH RKETVM BY <br />❑ INDUSTRIAL <br />❑ OPEN BOTTOM <br />DIA. OF WELL EXCAVATION <br />n Y1C VIZ <br />DIA. OF CONDUCTOR CASINGI V ( 1 <br />❑ DOMESTIC/PRIVATE <br />GRAVEL PACKMME <br />TYPE OF CASING/STEEL/PVC <br />111I1l1 <br />V J l.. <br />DIA. OF WELL CASING Z <br />❑ PUBLIC/MUNICIPAL <br />❑ DRIVEN <br />DEPTH OF GROUT SEAL <br />cal <br />SPECIFICATION SZ 6 i} 1 <br />❑RR <br />IRRIGATION/AG <br />❑ OTHER <br />GROUT SEAL INSTALLED BY <br />.CSL ��L. <br />GROUT BRAND NAME <br />® MONITORING <br />GROUT SEAL PIMPED: ❑ Ys <br />13Ne <br />CONCRETE PEDESTAL BY DRILLER: M Ys ❑ Ne <br />APPROX. DEPTH I (� 1 1) LOCKING CHESTER BOX/STOVE PIPE <br />PROPOSED CONSTRUCTIONMAILLING METHOD: MUD ROTARY AIR ROTARY AUGER_ CABLE OTHER <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE M ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES. STATE LAWS, AND RULES AND <br />REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'$ 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 SUBCONTRACTING SIONATURE CERTIFIES <br />THE FOLLOWING: - I C ERM <br />THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORIONAN-S SATION LAWS OF <br />CALIFOF!NI HE�MTVST CALL M HOURS IN ADVANCE FOR ALL REQUIRED tNS►fdCTIONS AT CLOSI 4gJ423. COMPLETE DRAWING AT LOWER AREA PROVIDCOM jED <br />Signed X THIS T .1.7-"'7'-z L (. �...... `( f <br />Data <br />I -ROT PLAN (Draw to SeaW Bub ' to <br />1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LACAT)ON OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />2. OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. 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 ADJOIFRNG PROPERTY. <br />DEPARTMENT USE ONLY <br />Application Accepted <br />Date 4 -f - <br />f -7 Ns (Pf <br />Grout Inspection By �-4 Date Pump Inapectlm By Date <br />Destruction Impaction <br />ACCOUNTINO ONLY: I AID# <br />FAG <br />rim <br />PE CODES <br />FEE INFO <br />AMOUNT RBWTTED <br />I jCHECK#CASH RKETVM BY <br />DATE <br />ISERVICE'RE ER <br />INVOICE <br />cal <br />