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APPLICATION FOR WELLIPUMP PERMIT is <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P,O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201-388 <br /> (209) 4683420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete iB 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 /> �9-1115.3,.A,N/D THE STANDARDS OF SAN JOA N COUNTY PUBLIC IIEALT14 SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESS/OR APNN �t/' �(/V ,�TJne— �. j�,�� �d " `hT pC ARCEL SIZE/APN► <br /> OWNER'S NAME _ ADDRESS__ ( {_ Sp3 <br /> ���CeaC.��.f/ +y PHONE A' <br /> CONTRACTOR r7(/�'✓►I iFQIJU/��/)m.� . ADDRESS ��(_J3j/!� UCI V�JO?�7 {.y{ONE I / 0z*y <br /> SUB CONTRACTOR "or, / ADDRESS / UCI PHONE i <br /> TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL it ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ ,/ <br /> (TYPE OF PUMP1 ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL I L2SOIL BOPoNG B <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 2`2 S n DIA.OF CONDUCTOR CASINO D <br /> ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEEUPVC DIA.OF WELL CASING D <br /> ❑ PUBLIC/MUNICIPAL ❑DnIVEN DEPTH OF GROUT SEAL �h SPECIFICATION is q <br /> ��❑ IR""RIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY •C>R�_ Ir GROUT BRAND NAME ry E <br /> I..r/��AONITORmINO GROUT SEAL PUMPED: ❑Ya• rve CONCRETE PEDESTAL BY DRILLER:❑Yea S <br /> APPROX.DEPTH to . J LOCKING CHEBTEn BOX/STOVE PIPE 5 <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHE _ <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:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT 18 ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,18HALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.'Tyf APP NT MUST CALL 2.4 ROUP IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12001409-3422. COMPLETE DRAWING AT LOWER AREA PROVIDE <br /> 8lpnwdX Title �T-sf" D•te�/�7 <br /> PLOT PLAN 10—to Se•tel Scale 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO On 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 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 /> S91 >- <br /> C; <br /> r <br /> DIA <br /> DEPARTMENT USE ONLY Applleatlon Aeoepted BData � `` ( � A­ <br /> Grout Impaetlon By Date Pump Inapeetlon By Date <br /> Da•trtretlen impec�tlonBy Y� "� Date <br /> CommenU: 1 5�—,XII"' Uv bjed Approua b Lf'Q SCD (4 AOY-K ✓ d 1'ZI' �cr <br /> L.IG vLl2 c�1D✓► 141 �lf5few 0� VJOr n L.✓1 W <br /> j <br /> ACCOUNTING ONLY: AID/ FAC/ S 3G Wei SFr. ©/l L`P <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE '1 <br /> D "0PRIC, 1.21 <br /> Pub.Health Serv.-Enviro.173(3/96) <br />