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i <br /> APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAaUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOAOUIN ST., STOCKTON, CA 95201.388 <br /> (209) 486.3420 <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 ANDIOR 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 ADDRESMR APN# 393 5 F_yC h er-ok ee �?-/el C /GG f Q NI PARCEL SIZEIAPN# �( <br /> OWNER'S,AME C�CCJ`I a* r. CL`C-+'l I/i I C`7lJl�L{I�F7C�L�, ADDRESS_ I ZI / 1+4/ST. {?H GI C- YJ PHONE <br /> L I+U6--Sj e e, r�I try I /, �O? �(/ ' <br /> �ORACTOR V !/(0' Z lL ,Lam-ADORES& / `(�� ucy�I j"J'" PHONE.r 2 r�.1 /W�j) "�//71/�� <br /> �t76 CdtJiAJA O -. <br /> ADDRESS o elS l�Cy PHONER.] (O�'8. <br /> TYPE OF WEUtPUMF' EW WELL ❑ REPLACEMENT WELL MONITORING WELL#U5-f—Z131 ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL It J <br /> ❑New❑Repw, H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL D <br /> (TYPE OF PUMP( <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELLM ❑ SOIL BORING @ <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE Of WELL CONSTRUCTION SPECIFICATION& A <br /> ❑ INDUSTRIAL ��❑��((OPEN BOTTOM DIA.OF WELL EXCAVATION / DIA.Of CONDUCTOR CASING D _ <br /> ❑ DOMESTIClPRIVA7E iL�S,GRAVEL PACKlSI2E TYPE OF CASiNGlSTEELlPVC V G — DIA.OF WELL CASING_ y/ D <br /> ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL__(a 0 SPECIFICATIONIfJ-L_—_�.y. R <br /> ❑ 1RRIGATIONIAG ❑OTHER GROUT SEAL INSTALLEO SY.Ijl '4Y�,���,,,,,,��-^.T�ilil GROUT BRAND NAME �� E \V1J <br /> XMONITORING / GROUT SEAL PUMPED: ❑Yea)am. CONCRETE PEDESTAL rJ BY DRILLFR: Yee ❑No S <br /> APPROOL DEPTH 9 n LOCKING CHESTER BOXtSTOVE PIPE F11,J h-mu"KJ- S <br /> PROPOSED CONSTRUCTIONIOIRILINO 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 <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 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 SUBCONTRACTING 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'$COMPENSATION LAWS OF 1� <br /> CALIFORNIA.- N£APPIJC,rA�NfT MUST <br /> �CALL <br /> I24 HHOUR'S,IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT[+2091 400-423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> sg fy�-C 1 Tltla_ Data_��/7- / _♦ <br /> PLOT PLAN IDrow to Sudel Seta 'to - <br /> I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPAN64ON OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF AU.EXISTING AND PROPOSED 6. LOCATION Of WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. Ch <br /> :.......i...... ....:.....,.... .........:......i.....,..... ........ .,. ...... <br /> DEPARTMENT USE ONLY 9S �1Try <br /> Appliee9on Accepted BY Dale / Arm <br /> Gteut Irwpecdnn BY Date Pump Inwpecdon By Date <br /> IV <br /> Dmvvctlon Itwoeetlee By � Date <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CGOES FEE INFO AMOUNT R15MITTED CHECK#ICA$H RECOV52 BY DA PERMITISERViCE REQUEST NUMBER INVOICE <br /> o aI 3 95 MoD SIo c� <br /> I <br /> C(OPY <br />