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0 <br /> APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201.388 <br /> (209) 468-3420 <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 AND/OR INSTALL THE WOR(DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TR�L/(��'CHAPTER 9-1115.3/A�N�OLT//E STTANDARBb-PF JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. /L <br /> JOB ADDRESSOR APNJ I� I % Z S^-' /V/1I `/��A{{-�tII JCC CITY PARCEL <br /> l/{/c%� �Ll PARCEL SRE/APN/ <br /> OWNER'S NAME _FI'�r VIGI ( 1�`FWl4 C/' / //( ADDRESS�/��7�^�tC, .rIPI/I'/�,LnI—L 7 ISI CS�J�I J )PHONE f �( <br /> CONTRACTOR_ l ./1 I -I L 14 LA AODREf:63 L,-1 T C• (�BLVj'1 J�6� UCJ I.J (F PHONE f �7 TJ <br /> SUB CONTRACTOR ADDRESS LICE PHONE R <br /> TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL f ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL• J <br /> ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0 <br /> RYK OF RUMP) ( �,, <br /> r <br /> 7 11OUT-OF-SERVICE WELL yl0 ❑ GEOPHYSICAL WELL• ❑ SOIL SOR�INNG B <br /> E6TRUCTION: 1 / C lU'j /j IZII rl e 17P T T I /r t'V <br /> INTENDEDTYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> C3 INDUSTRIAL INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOfl CASING 0 N <br /> 13 /PVC DOMESTIClPRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINGlSTEELDIA.OF WELL CASING D LP <br /> ❑ PUBUCMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> GROUT BRA <br /> E3 IRRIGATION/AG 13OTHER GROUT SEAL INSTALLED BY ND NAME F Q <br /> ❑ MONITORING GROUT SEAL PUMPED: ❑Vs ❑No CONCRETE PEDESTAL SY DRILLER:Ely. ❑Ne S � <br /> APPROX.DEPTH LOCKING CHESTER SOX/eTOVE RPE A <br /> S <br /> PROPOSED CON6TIIUCTION/OW WNO METHOD: MUD ROTARY AIR ROTAflY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WRH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULFS ANO ¢ <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 WOW FOR WHICH <br /> THIS PERMIT IS ISSUED,I NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPEN6MRON LAWS OF CAUFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: C IFY T ITHE P RMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'{COMPENSATION LAWS OF <br /> CALIFORNIA.' E AIT T 7 IN ADVANCE FOR ALL REQUIRED IN�PE�TpNf r I���j M-7 <br /> �MP /E DRAWING AT LOWER AREA PROVIDED. <br /> Slorwe X J///J\ L 7�I1L�I �.� <br /> Dote <br /> PLOT PLAN IDrn to S o)Gula 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 6. LOCATION OF MOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 1. 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 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. <br /> NOV - 7 199 <br /> �I <br /> DEPARTMENT USE ONLY <br /> AOpliuticn Acceptetl BY -�/'—' Dete Aru� <br /> Grout lmtion BY Dote Pum,Inepectlen BY �1 Ona <br /> DmtructlonImpmtb �By q '^- , •-- �' - Dna -I / <br /> Commmte: 1007 V� ��. ••L�� O - <br /> ACCOUNTING ONLY: 1 AIDE 1 FACE <br /> PE CODES FEE INFO AMOUNT REMITTED EC /CASH I RECOVED BY DATE PFRAtIT/6FRVICE REOUEST NUMBBt INVOICE <br /> S I -1 5 � oa3 0 <br />