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Date Date // 0 Pump Inspection By <br />Application Accepted By <br />Grout Inspection By <br />14-go-t-q <br />91 <br />Date <br />DEPARTMENT USE ONLY <br />tOf <br />Area q <br />APPLICATION FOR WELL/PUMP PERMIT <br />,AN JOAQUIN COUNTY PUBLIC HEALTH SERVIL <br />ENVIRONMENTAL HEALTH DIVISION <br />P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 95201-388 E.4TA,L HEALTli <br />(209) 468-3420 a SERVICE <br />NON•REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />rk1 10: 15 <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 <br />made in compliance with San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br />Services, Environmental Health Division. <br />Job Address/or APN# yvlr za. 49/w7 eie%vw A.-.K.) City -79N-A17Z'it) Parcel Size/APN# <br />e <br />Owner's Name -7-/'2/ ()(/). Address '/Ye/21 i/J ' Me-/i1)//7-61-1/r /el/ <br />Arc47 Phone # —27S3 <br />/ / <br />Contractor/k61 6-61 kii/i/eiiile4 ric: frlicldress /?‘ 3. 4.c' . 45, 4 / I. , 7) /9 L i c# ;A/2 -L. / Phone # /56 .6)'24-#1/ <br />Sub Contractor (//Virgy),14.16-e-- Address // Lic# (;dV 2 -I -// Phone # <br />TYPE OF WELL/PUMP: 0 NEW WELL <br />DESTRUCTION <br />INSTALLATION <br />New 0 Repair <br />(TYPE OF PUMP) <br />REPLACEMENT WELL <br />OUT-OF-SERVICE WELL <br />WELL SYSTEM REPAIR <br />H.P. <br />MONITORING WELL # 0 OTHER <br />GEOPHYSICAL WELL #M <br />( /) ISOIL BORING <br />CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELL # <br />DEPTH PUMP SET FT. FIRST WATER LEVEL <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF WELL EXCAVATION /4/Z- DIA. OF CONDUCTOR CASING <br />TYPE OF CASING/STEEL/PVC A),44 DIA. OF WELL CASING <br />DEPTH OF GROUT SEAL /5-/ SPECIFICATION /- <br />GROUT SEAL INSTALLED BY GROUT BRAND NAME 4/440./6%il-?-27-7- <br />GROUT SEAL PUMPED: 0 Yes ,tf/No CONCRETE PEDESTAL BY DRILLER: 0 Yes <br />LOCKING CHESTER BOX/STOVE PIPE <br />MUD ROTARY AIR ROTARY AUGER CABLE OTHER PROPOSED CONSTRUCTIONIDRILLING METHOD: <br />INTENDED USE TYPE OF WELL <br />0 INDUSTRIAL [] OPEN BOTTOM <br />0 DOMESTIC/PRIVATE 0 GRAVEL PACK/SIZE <br />0 PUBLIC/MUNICIPAL 0 DRIVEN <br />0 IRRIGATION/AG 0 OTHER <br />MONITORING <br />/,- / <br />/ APPROX. DEPTH ,1 <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, <br />State Laws, and Rules and Regulations of the San Joaquin County. Home owner or licensed agent's signature certifies the following: "I <br />certify that in the performance of the work for which this permit is issued, I shall not employ persons subject to WORKMAN'S COMPENSATION <br />Laws of California." Contractor's hiring or sub-contracting signature certifies the following: " I certify that in the performance <br />of the work for which this permit is issued, I shall employ persons subject to WORKMAN'S COMPENSATION Laws of California." THE APPLICANT <br />MUST CALL 24JLOURS 10rADVANfE FOR ALL RE UIRED INSPECTIONS AT (2011)488.3423. Complete drawing at lower area provided. <br />') <br />) / <br />v Title l'i/-24//Or (--iVi-e(G137r— <br />PLOT PLAN (Draw to Scale) Scale " to <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, <br />and walks. <br />Location of house sewage disposal system or <br />proposed expansion of sewage disposal systems. <br />Location of wells within radius of 150 ft. on <br />the property or adjoining property. <br />C. <br />(' <br />/ <br />Destruction Inspection By Date Comments: <br /> <br />ACCOUNTING ONLY: AID# FAC# <br />, ,,,, <br />PE CODES FEE INFO AMOUNT REMITTED cHEfigoAsii RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br />.Fqc. 1.2-31 1-147- 'Yih(, ntos-c <br />y <br />Signed X <br />Date //