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APPLICATION FOR WELQPUMP'PEM0IT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERV; <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 85201-388 <br /> (209) 488-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM HATE ISSUED <br /> (Complete In Tripr'intal <br /> Application is here by made to the San Joaquin County for a permit to construct and/or instalt the work described. This application is` <br /> made in comptience with San Joaquin]County Development Title, Chapter 1115.3 and 1he Standards of San Joaquin County Public Healthl <br /> Services, Environmental Health Division. $� -7&c7 p#-)"42, 2 F <br /> Job Address/or APN# ,, ✓:7_ "' it f City /��� Parcel Size/APH# <br /> Owner's Name A0111AI z;z� Address <br /> �� �� 7 �/01/s Phone # i <br /> -Contractor S . /GCCWLic# Phone # 3T�Q <br /> SubContractor •&H �f1t1z5 �' Address d <br /> a,& Lie# Phone #-s.5- <br /> TYPE <br /> S�.S- <br /> 1 <br /> TYPE OF HELL/PUMP,;NEW WELL [) REPLACEMENT WELL ❑ MONITORING WELL # 0 OTHER <br /> 0 DESTRUCT {1N_l 11 OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL # ❑ SOIL BORING <br /> [3 INSTALLATION [3 WELL SYSTEM REPAIR [3 CROSS-CONNECT REPAIR 13 VAPOR EXTRACTIOWELL # <br /> ew ❑ Repair H.P. DEPTH PUMP SET /30 FT. FIRST WATER LEVEL��I/� <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL ! CONSTRUCTION SPECIFICATIONS I <br /> [3 INDUSTRIAL [3 OPEN BOTTOM I DIA. OF WELL EXCAVATION Lay DIA. OF CONDUCTOR CASING <br /> DOMESTIC/PRIVATE AGRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC L DIA. OF WELL CASING <br /> [I PUBLIC/MUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> [] IRRIGATION/AG C} OTHER GROUT SEAL INSTALLED BY S GROUT BRAND NAME <br /> + i <br /> [3 MONITORING r GROUT SEAL PUMPED,-Ves [3 No CONCRETE PEDESTAL BY DRILLER: [3 Yes [3 No <br /> APPROX. DEPTH _ LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTRUCTIONIDRILLING METHOa.- MUD ROTARY 'A AIR ROTARY_ AUGER_ CABLE_ OTHER <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, <br /> State Laws, and Rules and Regulations of the San Joaquin County. Home owner or licensed agent's signature certifies the. following: "I <br /> certify that in the performance of the work for which this permit is issued, I shall not employ persons subject to WORKMAN'S COMPENSATION 7 <br /> Laws of California." Contractor's hiring or sub-contracting signature certifies the following: 11I certify that in the performance <br /> of the work for which this permit isi' sued, I shall employ persons subject to WORKMAN'S COMPENSATION Laws of California." THE APPLICANT <br /> MUST GAIT 24 A ANCE CUIRED INSPECTIONS AT(201)468-7423. Complete drawing at lower area provided. <br /> Signed X �� Title cJ Date <br /> PLOT PLAN (Draw to Scale) Scale a to <br /> 1. Names of streets or roads nearest to or bounding the property. 4., Location of house sewage disposal system or <br /> 2. Outtine of the property, giving dimensions and North direction. proposed expansion of sewage disposal systems. <br /> 3. Dimensioned outlines and location of all existing and proposed 5. Location of wells within radius of 150 ft. on . <br /> strOctures, including covered areas such as patios, driveways, the property or adjoining property. <br /> and walks. i <br /> ]I <br /> I <br /> i f <br /> n <br /> f Q � <br /> Z � <br /> a <br /> � w <br /> JB IC, H k.L H 5 <br /> 'LLFEL ::L.—Lw-� <br /> DEPARTMENT USE ONLY 75 <br /> I <br /> Application Accepted By I a [ Date Area <br /> Grout Inspection By Date L Pump inspection 8 Date--i `� I <br /> Destruction Inspection By E Date Comments: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMPAT REMITTED HE lICASH RECEIVED BY DATE PERMITISERVICE REOUEST NUMBER INVOICE <br /> (' O <br /> 44a. I 3� L� <br />