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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 JOAQUIN ST., STOCKTON, CA 95291.388 <br /> (209) 488-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROIN DATE ISSUED <br /> (C4mpl4is in Triplicat4) <br /> APPLICATION 15 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORT[DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE, <br /> /CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC 14EALTH SERVICES,ENVIRONMENTAL HEALTH A1VfS0.0%.. <br /> JOB ADDRESSIOR AFNN �,= IVIfL'>'LL �/7f-� ._ 'ITV /til _ PARCEL7�SIZEIAFN,!_ <br /> OWNER'S NAME �� 'T� �, "f .'� AOOAES �• (J[F.L.I� �J•`+�-r���� ,�'�I ONEX <br /> CONTRALTO -r[--$C,%LL-�T�J�-' _ ADDREES�A!! U, fL� W -W-4 LSC; _PHONE I' <br /> SUB CONTRACTOR-�'�/Y E�tiyp/�, Ir �f'r'✓ - ADDRESZ' 5� LICN� .[9 - I <br /> 7 PHONE/ S <br /> TYPE Of WELLIPUMR ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I OTHER I►" J_'J;•T+r'< <" S <br /> ❑ INSTALLA'.IOM ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR VAPOR EXTRACTION WELL i J <br /> ❑Now❑Reperr N.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> fTYPE OF PUMP) �-� <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELLIr ❑ SOIL BORING B <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFfCATIONS I A <br /> l!----11 i( l� <br /> ❑ INDUSTRIAL L1 OPEN BOTTOM DIA.OF WELL EXCAVATION U DIA. OF CONDUCTOR CASING -2f D— <br /> ❑ DOMFSTICIPRIVATE GRAVEL PACKISIZE TYPE OF GASINGISTEELIPVC rCr MA.OF WELL CASING -2 I D -Z <br /> ❑ PUBLICWUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL vAfq iv SPECIFICATION 1� <br /> ❑ IRRIGATIONfAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME VA Tbft b <br /> MONITORING GROUT SEAL PUMPED: ❑Yea ❑No CONCRETE PEDESTAL BY DRILLER:❑Yr ❑No S <br /> APPROX.DEPTH LOCKING CHESTER BOXIS'TO VE PIPE_ S <br /> PROPOM CONSTRUCTIONIONLUNQ METHOD: MUD ROTARY_ AIR ROTARY AUGER CABLE OTHER Q <br /> I HEREBY CERTIFYTHAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WALL RE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES ANO <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLiOWMG: '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 64GNATLIRE CERTIHE&��••--�� <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PEA RMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALIL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OFA/ <br /> CALIFOfiNIAf71Tj E MUST CALL 24 048 IN ADVANCE FOR ALL REQUIRED INSPECTION4 AT 11 1/4811114423. <br /> COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Signed% ,t Ttle r/- G�t �.'�(•�IFI, r/�� _ _ Data i2--4 <br /> PLOT PLAN (Draw to Scale)Scale 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST O OR BOUNDING THE PROPERTY. 4. LOCATION Of HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING OIMCHWONS ANO NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> J. DIMENSIONED OUTLINFS AND LOCATION OF ALL EXISTING AND PROPOSED 6. LOCATION OF WELLS WFTHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS",DRIVEWAYS,AND WALpK�S..'� ON THE PROPERTY OR ADJOINING PROPERTY. <br /> I <br /> I 1 <br /> DEPARTMENT USE ONLY <br /> ny <br /> Application Accepted BY l Date L'' {- i t� .Area <br /> Grout Irupection By �1 .!'^ `" — Pate �•Pumt Inspection By ,Data <br /> Destruction Inspection By Date <br /> Commmu: o sa <br /> ACCOUNTING ONLY: AID49 FaCN 7 <br /> J I <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECOVED BY I DATE PERT/8E4%4CE REQUEST NUMBER INVOICE <br /> C ! _ <br /> (� oSb 61A fi <br />