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APPLICATION FOR WELLIPUMP PERMIT - <br /> _ SAN JOAQUIN COUNTY PUBLIC HEALTH SERV S <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O, BOX 388r 304 EAST WEBER AVENUE, STOCKTON, CA 9MI0 388 <br /> 12091468-3420 <br /> NON-REFUNDABLE PERMIT <br /> —1 <br /> APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANO/OR INSTALL THE WOM DESCRIBED, THIS APPLICATION IB MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9.1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH OIVISION, <br /> JOB ADDRESS/OR APN/ CRY PARCEL SIZEJAPN/ <br /> OWNER'S NAME ADDRESS PHONE / <br /> CONTRACTOR ADDRESS LICA PHONE / <br /> SUB CONTRACTOR ADDRESS IJC/ PHONE / <br /> TYPE OF WELLJPUMP: ❑ NEW/ WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM R Affl ❑ CROSS CONNECT REPAIR ❑ VAPOR EXTRACTION WELL / J <br /> ❑ Newt ❑ Rawlr H.P. DEPTH PUMP SET_FT. FIRST WATER LEVEL p <br /> RVPE OF PUMP <br /> ❑ Om-oF PUKE WELL ❑ GEOPHYSICAL WELL / ❑ SOIL SORING : S <br /> ❑ DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION BPECIMADON4 q <br /> ❑ INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING D <br /> ❑ DOMESTIC/PRIVATE ❑ GRAVEL PACJU82E TYPE OF CASINGMTEELIPVC DIA- OF WELL CASINO D <br /> ❑ PUBLICMUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ IRRIGATIONIAG ❑ OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITORING GROUT SEAL PIMPED: Clyne ❑ Na CONCRETE PEDESTAL BY DRILLER: ❑ Yea ❑ No S <br /> APPROX. DIETH LOOKING CHESTER BOX/STOVE RPE ,T <br /> PROPOSED CONSTRUCTIONMRWNO METHOD: MUD NOTARY AIR ROTARY AUGER CABLE OTHER <br /> I HE9EBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN 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: 01 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IB ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: ' I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUEO, I SHALL EMPLOY PERSONS SUBJECT TO WORMM49 COMPENSATION L.AWE OF <br /> CALIFORNIA.' THE ARl1CANT MUST CALL N HOURS IN ADVANCE FOUR ALL REUUMI® MB TDNB AT T2Be1 Neil]], COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> BIPr.e x TIN. Date <br /> ROT PAN (Draw to SpaNl Bola ' to <br /> 1 . NAMES OF STREETS OR ADAGE NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DEPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DNSPOM SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED E. 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 P(IPETRY. <br /> MAP ON BACK <br /> i <br /> DEPARTMENT USE ONLY <br /> Application Apunnd Br Dan Ar.. <br /> Grout IrnPoolian BY Dan Pt i ItuPaaUon BY Data <br /> Daavoetlon Inapamlm Br Dan . <br /> Colne <br /> ACCOUNTING ONLY: AUDI FAG <br /> PE CODES FEE INFO AMOUNT REMITTED CHECII/ICASH RECEIVED BY DATE PBBMITlBERVICE REDDEST NUMBER INVOICE <br />