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1 ff <br />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 95201.388 <br />(209) 468.3420 <br />NON-REFUNDABLE PERMIT EXPIRES i 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 <br />R9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR APNM G ` UL^' �^ '��GI CITY. ('L^� \ PARCEL SIZE/APN# <br />1I1r 1 4', �� S ADDRESS �r'-r,V ;� i/�� `-+� �)/�� C 9 5 <br />OWNER'S NAME 1 1 -v nI.n PHONE R _ - <br />I! _ rs e�z <br />CONTRACTOR ' 1 � �--T 1.1, , ^r', ADDRESS � 7. ? O{, � �I,J '. C. LIC# I YQ PHONES 701 <br />1 <br />SUB CONTRACTOR ADDRESS <br />UC# PHONE # <br />(TYPE OF PUMP) <br />❑ OUT -0F -SERVICE WELL ❑GEOPHYSICAL WELL # ❑ SOIL BORING <br />❑ DESTRUCTION: <br />❑ REPLACEMENT WELL <br />R MONITORING WELL or 111 <br />❑ OTHER <br />TYPE OF WELL/PUMP: ❑ NEW WELL <br />❑ INSTALLATION <br />❑ WELL SYSTEM REPAIR <br />❑ CROSSCONNECT REPAIR <br />❑ VAPOR EXTRACTION WELL # <br />❑ New ❑ Recall <br />H.P. <br />DEPTH PUMP SET FT. <br />FIRST WATER LEVEL O <br />(TYPE OF PUMP) <br />❑ OUT -0F -SERVICE WELL ❑GEOPHYSICAL WELL # ❑ SOIL BORING <br />❑ DESTRUCTION: <br />INTENDED USE <br />TYPE OF WELL <br />CONSTRUCTION SPECIRCATIONS <br />)p <br />f^1❑ <br />❑ INDUSTRIAL <br />❑ OPEN BOTTOM <br />DIA. OF WELL EXCAVATION <br />DIA. OF CONDUCTOR CASING <br />DOMESTIC/PRIVATE <br />® GRAVEL PACK/SIZE U I Z <br />TYPE OF CASING/STEELIPVC ?U i S(� "CI N <br />DIA. OF WELL CASING LJ <br />❑ PUBLIC/MUNICIPAL <br />❑ DRIVEN <br />DEPTH OF GROUT SEAL `> 'r } <br />SPECIFICATION <br />❑ IRRIGATION/AG <br />RI <br />❑ OTHER <br />GROUT SEAL INSTALLED BY > i �. �� �-- = <br />GROUT BRAND NAME <br />•© MONITORING <br />GROUT SEAL PUMPED: ❑ Yee ❑ No <br />CONCRETE PEDESTAL BY DRILLER: ❑ Vee ❑ No <br />APPROX. DEPTH -q J LOCKING CHESTER BOX/STOVE PIPE <br />PROPOSED CONBTRUCTION/DRIWNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOR( WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, ANU KU"ANU <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 WOR( FOR WHICH <br />THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWINT. ' I',CERTIFY THAT IN THE PERFORMANCE OF THE WOR14FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CALIFORNIA.' THE APPLICANT MUST CALL 24 HOLWA IN ADVrXrCFiECiZ4iED INSPECTIONS AT 12011 4ei3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />f / <br />1 1 /� J" / <br />Signed X^� / r Title aDete <br />I /�� <br />PLOT PLAN (Drew to Sine) Sole ' 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 />J. 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 />y14 '730 , a/ S t <br />ACCOUNTING ONLY: I AID# <br />PE CODES FEE INFO AMOUNT REMITTED <br />FAC# <br />CHECKY/CASH RECEVED SY <br />,c__ <br />DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />