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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVI <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201.388 <br /> (2091468-3420 <br /> WON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICompkb in Trglico l <br /> APPLICATION 15 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION I6 MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAGUIN <br /> COUNTY PUBLLICI'HEALTH <br /> EALTH SERVICES,yENVIRONMENTAL HEALTH DIVISION.DIVISION. <br /> JOB ADDRSSORAPNN 16aDqRNarpMCI \DA-P CITY UNTYTlqt t% PARCEL SIZE/APNN5 <br /> OWNER'SNAME (<CKLERADDRESS PHONE#133 <br /> I2CONTACTOR U` LIADDRESS � 73d�CHONE#24pl <br /> SUB CONTRACTOR V PHONET^a / 2� <br /> LY'[71' <br /> [j� <br /> TYPE OF WELL(PUMP: T❑ NEW WELL ❑ REPLACEMENT WELL py MONITORING WELL N— ❑ OTHER <br /> LJ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# <br /> ❑Naw❑Repair H.P. DEPTH PUMP SET_FT. FIRST WATER LEVEL D <br /> TYPE OF PUMP) <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# SOIL BORING S <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION LI DIA.OF CONDUCTOR CASING NSA 0 <br /> ❑ DOMESTIC/PNVATE ❑GRAVEL PACK/SIZE TYPE OF CASINGISTEEL/PVC � DIA.OF WELL CASING <br /> '�1 x 0 <br /> SI <br /> ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL --- SPECIFICATION % 4U A <br /> 11IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BV `{yGROUT BRAND NAME E <br /> �MONTORING / GROUT SEAL PUMPED:jY. ❑N. CONCRETE PEDESTAL BY DRIUUFR Ys ❑No S <br /> APPROX.DEPTH LOCKING CHESTER BOXI6TOVE P ��' 444444 S <br /> PROPOSED CONSTRUCTIONIdtlWNO 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 UCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW 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 FOLLO NG: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA. THE AP CAT MT CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED <br /> /I�NGFECTIOONTB�AATT(22M))44141SCOMPLETE DRAWING AT LOWER AREA PROVIDED <br /> sones X a Title _W 1�i 128 y � Date 35 <br /> _ <br /> Plu AT PLAN(Drew to Stale)Scale'to� <br /> 1. NAMES OF STREETS ORIO ADS 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 DI6POS J.SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 5. 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 /> v <br /> VIP <br /> fr <br /> © z <br /> " v N <br /> omv)3 <br /> DEPARTMENT USE ONLY <br /> Application Accepted B /// I� �I��U,.' Data <br /> Grout Inpoction By Date�'bl�Fes_ Pump Inpectlan By Data <br /> D.ruetlon InpmtioTn�B1Y� �J —I{��\ ( Data <br /> Comm.., fin'✓L / 4 I llY iI ce <br /> ACCOUNTING ONLY: AID# FAC# <br /> PF CODFB FEE INFO AMOUNT R@AITTED CNE...... SH RECDVED BY DATE P6IMITIBFRVICE REGUFBT-----— <br /> INVOICE <br /> w5o� -1 - <br />