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APPLICATION FOR WELLIPUMP PERMIT <br /> ­—SAN JOAOUIN COUNTY PUBLIC HEALTH SERVt.,rS <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201-388 <br /> (209) 468.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES t 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--111 1.11 5..13 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEEjA�LTTH� SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESS/OR APN�N1 300 S. � a"V/ ,l 1A, J- CIIT,.Y� SARI Ce }/�,V�/�I�y //�PARCEL SIZE/APNN <br /> OWNER'S NAME .��II � ��IA6,✓}Jy�._ O �l'V4,,r6Z ADDRESS�7`� W ��y,GO//J'•�l�'AC.I �"�r�tu/�,u•�c_ PHONE# }r+'7p�77�/2pr7� <br /> CONTRACTOR Gid fL ► -e1/,J�j��„�,,� t ADDRESS I Z�,�'T I(A,Y'1Ti�L lam`(✓ILJCN �C PHONE Xaa!J37p /3L��/ <br /> SUBCONTRACTOR:"'1(I (111 I t D r I)I. -1 Lt bk1yj yY)1P 1('n V ADDRESS PD 80 X aa3� Rl�.it'1ChO UCx & PHONE 49"55 -W !7 <br /> �p1 <br /> TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ICL MONITORING WELL# ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J (�,) <br /> ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O 8 <br /> (TYPE OF PUMP) �} <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING B <br /> ❑DESTRUCTION:_ d <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONSQ� A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION I A DIA.OF CONDUCTOR CASING D <br /> ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC vc DIA.OF WELL CASING .yL ,/I( _ D <br /> ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL_ 317 SPECIFICATION A(L°-14J ,/ R <br /> �❑l IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY �1Z�''/.LXI V���'L/- GROUT BRAND NAME •��: /./G1i��9((L''C e E �� <br /> 0 MONITORING �` //� GROUT SEAL PUMPED: ❑Yes Q No CONCRETE PEDESTAL BY DRILLER:151Yaa [IN, S <br /> APPROX.DEPTH 6-J T LOCKING CHESTER BOX/STOVE PIPE S <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 AND tf� <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.- THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIO,/N$AT(209)468-3423,.. COMPLETE DRAWING AT LOWER AREA PROVIDED, U <br /> SIQr»d X '�'K7 J^-� l / Title /!/V y /'L�'�/!iC �C. 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. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> 1^/L-�1IL DEPARTMENT USE ONLY �/' <br /> Application Accepted By �\• I�Yl1�T''V` Date �I�-"I�� Area <br /> Grout Inspection By � \VrS+M Date,_Pump Inspection By Date <br /> Destruction Inspection By Date <br /> Comments: ` xiisgi w_"W�— <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />