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AW+ <br />APPLICATION FOR WELLIPUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SER'_ .; <br />ENVIRONMENTAL HEALTH DIVISION <br />P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201.388 <br />(209) 468.3420 <br />NON-REFUNDABLE PERMIT EXPIRES 9 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, CHAPTER <br />y9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY yP/UBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR APNX 1>'I{ /1� ( /)F G� /l-& L-� Zk CITY �1 r/pe,G ``I' / / 1 PARCEL SIZE/APNX /Zz /, <br />OWNER'S NAMEL/' 22`///4/ ADDRESS /? G�'�//%OTp1.2le" (.L�,11, ` �� ����G / PHONE# x.34 -f ,SV -74 <br />CONTRACTOR ��/ _J/ ADDRESS-3Z'V// LS' I ^/^/& AQ, /El'Gr'y(C0LIC#� Z ` - PHONE — / 7/ <br />SUB CONTRACTOR_ G!(/ (/WN.V�(� fi I%��JLGcS . ADDRESSh50 4/' /t"I L,A *A_L1C# PHONE <br />TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL # ❑ OTHER <br />,�/ ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS -CONNECT REPAIR ❑ VAPOR EXTRACTION WELL # J <br />"rS ❑ New ❑ Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br />(TYPE OF PUMP) _ <br />❑ OUT -OF -SERVICE WELL ❑ GEOPHYSICAL WELL # SOIL BORING <br />❑ DESTRUCTION: <br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br />❑/INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WELL EXCAVATION �J DIA. OF CONDUCTOR CASING /v(�- D (,� <br />,RJ DOMESTIC/PRIVATE ❑ GRAVEL PACK/SIZE TYPE OF CASING/STEEUPVC /1� j/{' DIA. OF WELL CASING N (�- D v' <br />❑ PUBLIC/MUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL S> SPECIFICATION A.. R <br />1,i1 ❑ IRRIGATION/AG ❑ OTHER GROUT SEAL INSTALLED BY GROUT BRANDNAME. ��`'->L,17�'•l E-�PL��' E <br />❑ MONITORING GROUT SEAL PUMPED: Yea ❑ No CONCRETE PEDESTAL BY DRILLER: ElYw-0 No S <br />APPROX. DEPTH .% 77 LOCKING CHESTER BOX/STOVE PIPE <br />PROPOSED CONSTRUCTION/DRILLING 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 IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES ANDl <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: " I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CALIFORNIA.'. AP ST CALL 24 HQIJRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT (209) 4683423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Slpr»d X / Title <br />� I� f Date <br />PLOT PLAN (Draw to Scale) Scale " 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.PANSION OF SEWAGE DISPOSAL SYSTEMS. <br />3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AIM,, FfOPO.S�MJ <br />�� � � � ION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />Ff11±CV <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOLDRLAO PROPERTY OR ADJOINING PROPERTY. <br />ACCOUNTING ONLY: i AID# I FAC# <br />'PE CODES FEE INFO <br />AMOUNT REMITTED HEC /CASH <br />RECEIVED BY <br />DATE PERMIT/SERVICE REQUEST NUMBER <br />INVOICE <br />l>o <br />\ iN q <br />