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APPLICATION FOR WELLIPUMP PERMIT <br /> 3AN JOAQUIN COUNTY PUBLIC HEALTH SERV)�_s <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 3BB, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201 .388 <br /> (209) 468.3420 <br /> NOR-REFUNDABLE PERMIT EXPIRES 9 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 /> JOAGUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESS/OR APN# 845 E . Charter W'Ta�y CITY Stockton PARCEL SIZE/APN* <br /> OWNER'S NAME <br /> � D8. F . �� IJO m� 1ADDRRESS � /' S-v-�-al G$ff4--F 1Tit5< o. C�ga?HONE #537 - 0771 <br /> CONTRACTOR V "' s� C A YI D i)°�VpuORESSZ�� J t't - � ,.��. UC# .+dam-tom 7 U PHONE/// -}/.g ,l <br /> FEF% U AL - a u 073 . PHONE # Y 6✓ O [ 1 <br /> SUB CONTRACTOR ADDRESS LIC# <br /> 1 <br /> TYPE OF WELUPUMP: ® NEW WELL ❑ REPLACEMENT WELL ® MONITORING WELL # I OTHEN�r <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL J <br /> RVPE OF POMP <br /> 11New ❑ Repair H.P. DEPTH PUMP SET_FT. FIRST WATER LEVEL O <br /> E� <br /> 11OUT-OF-SERVICEWELL 11R3 <br /> GEOPHYSICAL WELL # SOIL BORING <br /> ❑ DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WELL EXCAVATION 8 • 5 " DIA. OF CONDUCTOR CASING D <br /> ❑ DOMESTIC/PRIVATE ❑ GRAVEL PACK/SIZE # 3 S a n d TYPE OF CASING/STEEL/PVC PVC DIA. OF WELL CASING oo?40 D <br /> ❑ PUBUC/MUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL X S ij' SPECIFICATION YI�PGpy�He ,.,. �q �/ R <br /> E❑�TT IRRIGATION/AG ❑ OTHER GROUT SEAL INSTALLED BY O0 iLe GROUT BRAND NAME � G PI`�LI�- E <br /> LAa MONITORING GROUT SEAL WMPEO: ❑ Ys <br /> 10 No CONCRETE PEDESTAL BY DRILLER: ❑ Ys GJrve S <br /> APPROX. DEPTH LOCKING CHESTER BOX/STOVE PIPE S <br /> PROPOSED CONSTRUCTION/MBLUNO METHOD: MUD ROTARY AIR ROTARY AUGER .Y CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOR( WILL SE 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 <br /> WORK FOR WHICH <br /> THIS PERMIT IS ISSUED, I SHALLN T EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: ' I CERTIFY AT IN 1 RFORMANCE OF THE WORK FOR WHICtHj�PMR IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' 7 APPIIC MUS HOURS IN ADVANCE FORRON ED/IN/NSPFCTIONS AT I200L 4883423. COMPLETE DRAWING AT LOWER AREA PIR�JyO/V//1D/cTGyy' <br /> Slened X Titlej <br /> PAT PAN (Drew to Sole) Scale / ' to (1 <br /> ZAMES STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> F 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. <br /> STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> IF IF III I IF <br /> or <br /> IF <br /> 51 <br /> �s; ref <br /> IF <br /> _ IF <br /> L <br /> DEPARTMENT USE ONLY / <br /> Application Accepted By r ` Date { lI Arm FIFFIFFIFF <br /> Grout Irupection By Date Pump Inspection By Data <br /> Dectructlon Inspection By Data <br /> Comments: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHEC /CASH I RECEIVED BY DATE, PERMIT/SERVICE REQUEST NUMBER INVOICE <br />