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I APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOADUIN COUNTY PUBLIC HEALTH SERI' <br /> I 0 " ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOADUIN ST., STOCKTON, CA 95201-388 <br /> (209) 468.3420 <br /> NONREFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> (Complete is 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 <br /> made in compliance with San Joaquin county kevelopment Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br /> Services, Environmental Health Division.. � ++ ��,,�� <br /> Job Address/or APN# - - ✓ Lzyb <br /> � City ) Parcel. Size/APN# <br /> Owner'sNa �,, 1 � I l Address 66 Phone # <br /> m/el <br /> Contractor�o&rr L.Y k---,T , ''�1/1 Address�U- e7�l -2Z�S Lic#�3H j Phone #,239—.�.a��/a <br /> Sub ContractoA,�g REEK' �L.C�'r(:-r Address t;?S3a 01,UES. Cn Lic#���e7C Phone #5517-5-X 7 <br /> TYPE OF WELL/PUMP: ❑ NEN WELL [) REPLACEMENT WELL [1 MONITORING WELL # [1 OTHER <br /> [] DESTRUCTION [) OUT-OF-SERVICE WELL [I GEOPHYSICAL WELL # ❑ SOIL BORING <br /> _ 'INSTALLATION ❑ WELL-L, SYSTEM REPAIR [] CROSS-CONNECT <br /> REPAIR [I VAPOR EXTRACTION WELL #_ <br /> K,New I] Repair X.P. '/.� DEPTH PUMP SET 95 FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) ( �.. <br /> �� i7i,P6/.v€ avyo/wEz-c c%v.rs- /sris /s /�v.ro OreyiT 6.��y <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> 11 INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING <br /> 11 DOMESTIC/PRIVATE [] GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVL DIA. OF WELL CASING <br /> [1 PUBLIC/MUNICIPAL [] DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> [I IRRIGATION/AG [] OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME b: <br /> ❑ MONITORING GROUT SEAL PUMPED: [I Yes [I No CONCRETE PEDESTAL BY DRILLER: ❑ Yes ❑ No <br /> APPROX. DEPTH LOCKING CHESTER BOK/STOVE PIPE <br /> PROPOSED CONSTRUCTIONIDRILLING METHOD: MUD ROTARY_ AIR ROTARY_ AUGER_ CABLE_ OTHER_ <br /> 1 <br /> I 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 <br /> Laws of Cal- - ' Contractor's hiring or subcontracting signature certifies the following: I- I certify that in the performance L <br /> of the <br /> for which this permit is - sued, I shall employ persons subject to WORKMAN'S COMPENSATION Laws of California." THE APPLICANT <br /> MUST LL 24 HOURS IN DV NCE FOR UIRED INSPECTIONS AT(202)4683423. Complete drawing at�Ltowee�r1 area provided. <br /> Signed Title '-1/X • Date /1�41 <br /> PLOT PLAN (Draw to Scale) Scale " to <br /> 1. N s of streets oroads nearest to or bounding the property. 4. Location of house sewage disposal system or <br /> 2. Outline 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 /> structures, including covered areas such as patios, driveways, the property or adjoining property. <br /> and walks. <br /> Q <br /> Q. <br /> L � <br /> _x <br /> ,a <br /> 7 I CrB. <br /> z <br /> s y <br /> o <br /> w <br /> DEPARTMENT USE ONLY I <br /> Application Accepted By Date 4 <br /> rea Z <br /> Grout Inspection BY Date Pump Inspection By . -r Date ;`y <br /> Destruction Inspection By Date Comments: I/V.—e acC. .l . <br /> — 7 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK CASH RECEIVED BY I DATE PERMITISERVICE REDUEST NUMBER INVOICE <br /> o 45 c� C <br /> 0 21� <br />