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APPLICATION FOR WELLIPUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P.O. BOX 338, 304 EAST WEBER AVENUE, STOCKTON, CA 95201-388 <br />(209) 468-3420 <br />690 Y7E7 <br />11011-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, CHAPTER 9-1 1 1 5.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR APNe Ck. 9 6 /,fe n7e,'‘lr— 6:— crry 6-723C3Z72rP's./ PARCEL SIZE/APN. <br />OWNER'S NAME 0.041/E0,14(..- IS-7 -11LIE /4/4 ef4tec-0164Vr-eb . ADDRESS .1.25 Ba.sli cr v_c..riGhveisce,),09fiof <br />i PHONE e()1./5)254 -501 / ...„.„, <br />CONTRACTOR_A,eet a„...L, N., 6 t i 65 ri niy, i /...tc. <br />/ <br />ADDRESS CM idAve K), Alc 7-7 "rez.. UCe PHONE 167/0)31 3 -44!ii0 <br />SUB CONTRACTOR ADDRESS <br />LICS <br />PHONES <br />REPLACEMENT WELL <br />WELL SYSTEM REPAIR <br />H.P. <br />OUT-OF-SERVICE WELL <br />‘10 MONITORING WELL I <br /> <br />O OTHER <br />CROSS-CONNECT REPAIR <br /> <br />O VAPOR EXTRACTION WELL <br />DEPTH PUMP SET FT. FIRST WATER LEVEL <br />GEOPHYSICAL WELLS g SOIL BORING 513"•1 TIkete.i.rel-- 5B •-• I ,. g • <br />TYPE OF WELL/PUMP: 0 NEW WELL <br />0 INSTALLATION <br />0 Nev 0 Repair <br />(TYPE OF PUMP) <br />0 DESTRUCTION: <br />INTENDED USE TYPE OF WELL <br />INDUSTRIAL <br /> 0 OPEN BOTTOM <br />DOMESTIC/PRIVATE <br /> 0 GRAVEL PACK/SIZE <br />PUBLIC/MUNICIPAL <br /> 0 DRIVEN <br />IRRIGATION/AG <br /> 0 OTHER <br />)1Er MONITORING <br />APPROX. DEPTH <br /> 0 <br />PROPOSED CONSTRUCTION/DRIWNO METHOD: MUD ROTARY <br />CONSTRUCTION SPECIFICATIONS <br />if <br />DIA. OF WELL EXCAVATION ID <br />TYPE OF CASING/STEE -5-46cuct <br />DEPTH OF GROUT SEAL <br /> So , <br />GROUT SEAL INSTALLED BY at GROUT BRAND NAME <br />GROUT SEAL PUMPED: 0 Yee 0 No <br />LOCKING CHESTER BOX/STOVE PIPE <br /> AIR ROTARY AUGER2C <br />A <br />e-t/t DIA. OF CONDUCTOR CASING <br />DIA. OF WELL CASING al <br />SPECIFICATION <br />CONCRETE PEDESTAL BY DRILLER: 0 Yee 0 No <br />CABLE OTHER <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK VAL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND <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 CE 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. • TH T UST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT (200) 441S-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />I Title 51•0! FF.i r <br />PLOT PLAN (Draw to Seale) Seals <br />NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. <br />OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. <br />DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. <br />to <br />4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />DEPARTMENT USE ONLY <br />Sloped X Date <br />Application Accepted By .44,014' <br />!Me /1 /177/Kmp Inspection By <br />Date Area <br /> <br />.e <br />Grout Inspection By <br /> <br />Data <br /> <br />Destruction Inspection By <br /> <br />Date <br />Comments: <br />ACCOUNTING ONLY: AIDS FACS .')/ , <br />PE CODES FEE INFO AMOUNT REMITTED CHECK/MASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE - <br />-(ci •-5'--2 ( <br />r" ( .Y. ), qs IA, AI it I etifii Df)7 r 2- i <br />.---- -------„,