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APPLICATION FOR WELLIPUMP PERMIT , <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOAO.UIN ST., STOCKTON, CA 95201.388 <br /> M G �L�' -� is Ly 1� C,J , D r C- 09) 488.3420 <br /> NON-REFUNDABLE PERM EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complat$in Tripikst$) t <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115 3 A;T�iE STANDA DS OF SAN JO UIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSOR APN$ , AtLA2E> CITY PARCEL SIZ�/ <br /> 41 1A <br /> OWNER'S NAMEADDRESS # <br /> CONTRACTOR I S N ONE, U <br /> SUB CONTRACTOR ADDRESS LIC# PHONE# <br /> TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J <br /> ❑New❑Repair N.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> (TYPE OF PUMP) <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOk BORING e2WfB <br /> DESTRUCTION: / wrrk JgEgjg�: LJ -V- 0 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D <br /> ❑ DOMESTICIPRIVATE ❑GRAVEL PACKISIZE TYPE OF CASINGISTEELIPVC DIA,OF WELL CASING D n <br /> ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R 4 FFA <br /> ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITORING GROUT SEAL PUMPED: ❑Yea [IN. CONCRETE PEDESTAL BY DRILLER:Clyde ❑Ne S <br /> 1 <br /> APPROX.DEPTH LOCKING CHESTER BOXISTOVE PIPE SI <br /> PROPOSED CONSTRUCTION/DRILLINQ METHOD; MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL 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:"1 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 TS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF <br /> CAII ANT MUST CALL 24 HOU S IN ADVANCE R ALL REQUIRED INSPEC N4 AT 12091408-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. - {` <br /> Signed X U . !A /�. Tit a Data y <br /> PLOT PLAN IDrow to Scale)Scale "to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOGNOF 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. O <br /> STRUCTURES,INCLUDING COVERED Al $SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> ...... <br /> ,..,._ .. , ...,.. ....; X14 � - . <br /> 0 f � <br /> {� <br /> ... .. ... ... .. <br /> -Ra i <br /> PA`Y ENT <br /> REQ � <br /> .. .DEC.. 5 19 <br /> .o �o r. _ .... <br /> .. _ <br /> e <br /> NMEN A ALM, iJt`ti i l�l� . . <br /> SAN J4AQU1 <br /> PUF3LlG H.EA�-��;. <br /> ,... .: . .. ..'Evil,RO <br /> - 7-� 1 <br /> DEPARTMENT USE ONLY C' <br /> Application Accepted By /�-Cl.., ,- -,-_. Date Z. � �— A. <br /> Grout Inspection By Data Pump Inspection BY Date <br /> Destruction Inspection By Data z�f�� <br /> �� <br /> Commons. �' a <br /> IS <br /> ACCOUNTING ONLY: AID# FAC$ <br /> PE CODES PEE INFO AMOUNT REMITTED NEC !CASH RECBVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> S�Ro�o, � Z <br />