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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 95201.368 <br />(209) 468.3420 <br />NON-REFUNDABLE PERMIT EXPIRES 1 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 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR APN# I ,S �-� ItL^ Ij�CITY I L.� t PARCEL SIZE/APNN <br />OWNER'S NAME I •"� 1�I I��•'1-' �! I l�- ADDRESS �5),M�y i".Zii-'Q- 1�I,\'�'+ L;;i PHONE N <br />CONTRACTOR \i 21V-- l.J'.-+ II. ^� ADDRESS ? C. 1,'v� `• �tC�E•+ll�c,(ry LICX-7/&'X�_ PHONE +1 <br />SUB CONTRACTOR ADDRESS LIC# PHONE # <br />TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL A MONITORING WELL # /,D ❑ OTHER <br />❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS -CONNECT REPAIR ❑ VAPOR EXTRACTION WELL # ✓ <br />❑ New ❑ Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br />Cf`/PE OF PUMP( <br />❑ OUT -OF -SERVICE WELL ❑ GEOPHYSICAL WELL # ❑ SOIL BORING 8 <br />❑ DESTRUCTION <br />INTENDED USE <br />TYPE OF WELL <br />CONSTRUCTION SPECIFICATIONS 'r <br />❑ INDUSTRIAL <br />❑t1 OPEN BOTTOM <br />DIA. OF WELL EXCAVATION <br />1 <br />DIA. OF CONDUCTOR CASING <br />❑ OOMESTIC/PRIVATE <br />GRAVEL PACK/SIZE (E <br />TYPE OF CASING/STEEUPVC V l S(,1+� etR y �- <br />DIA. OF WELL CASING <br />❑ PUBLIC/MUNICIPAL <br />❑ DRIVEN <br />DEPTH OF GROUT SEAL _ S F, <br />SPECIFICATION <br />❑II IRRIGATION/AG <br />❑ OTHER <br />GROUT SEAL INSTALLED BY 17 +�� • v... r: <br />GROUT BRAND NAME <br />"1.]I MONITORING <br />GROUT SEAL PUMPED: ❑ Yea [IN. <br />CONCRETE PEDESTAL BY DRILLFR: ❑ Ys [IN. <br />APPROX. DEPTH 3-5 LOCKING CHESTER BOX/STOVE PIPE <br />PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER Y,,*- CABLE OTHER <br />I HEREBY CERTIATAT 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 N JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br />THI6 PERMIT ISSHALL NOT EMPLOY PERSONS'3UBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWINTIFY THAT IN THE PERFORMANCE OFT WO OR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CALIFORNIA." CANT MUST CALL 24 HO IN EQi. INSPECTIONS AT 12091 4463423. COMPLETE DRAWING AT LOWER AREA PROVID i <br />� <br />V <br />Slpnad X — - Title 1'Z '� +� Data <br />r <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 />DEPARTMENT USE ONLY /r <br />Application Accepted By �I I' "' � Date �)t Ls <br />;! - "/ y Ars ' `' C-_ <br />Grout lnspectlon By <br />Destruction Inspection By <br />Date Pump Inspection By Date <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHEC /CASH <br />RECEIVED BY <br />DATE PERMIT/SERVICE REQUEST NUMBER <br />INVOICE <br />r, <br />