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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 ka..n 318. 446 N.SAN JOAQUIN ST, STOCKTON, CA 86201.3$v— <br /> 1201) 4883120 <br /> NON REFUMDAIIt r[IIIHT, IIMRE! 1 YEAR FROM pats ittyrn <br /> 1Csmpbu he Tr`isstal <br /> Application Is here by wade to the Son Joaquin Canty for a perieit to construct and/or Instill es <br /> the work described. This aWt icstion is <br /> P%de in compliance with San Joaquin County Dv%elopaent Title, Chopter 9-1115.3 and the Standards of Son Joaquin Canty Public Health <br /> Services, E.rvirossents� Health DI-ision, <br /> Job Address/or/A�►Nf ZI�,A� /'.'ert.'y ✓�l / City �«/" ! Parcel Sfae/A►N/ _ <br /> Owner's Naas/� 'A C I',a': ///E Cyt.r/T Address .��! �'f _ phone / <br /> f n <br /> Contractor�E1T/a G,r,a:� _Addreas Licll Phns A�.i4•�/7 ]_� <br /> Sib Contractor !:Tilt-LIC? <br /> TC LI;y Address Lic/ Phone 0 <br /> TYPE OF YELL/PVW; 0 NEW WELL (1 REPLACEMENT YETI (1 MONITORING WELL B (1 OTHER <br /> (1 DESTRUCTION I] OUT-OF-SERVICE WELL U GEOPHYSICAL WELL 1 D SOIL ROBING <br /> J(INSTALLATION 1) WELL SYSiFM REPAIR (1 CROSS CONNECT REPAIR 11 VAPOR EXTR#CIION WCLI 0 <br /> S New (1 Repair M.P. 1 DEPTH PUMP SET 1'-Ij Ft. FiRST WATER LEVEL <br /> (TYPE Of PLN) <br /> �� TYPE M NEIL CBNSTMIC110R IPECIFIDATmm <br /> U INDUSTRIAL I) OPEN BOTTOM DIA. Of WELL EXCAVATION 1 t DIA. Of CONDUCTOR CASING <br /> fY1DIRIMIC/MIVAIt Jlr GAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC r K- DiA. Of WELL CASING <br /> a ftKIC/IRMICiPAL fI DRIVEN DEPTH OF GROUT SEAL /n 1 SPECIFICATION F <br /> n IMIGATTOO/AG (] OTNER GROUT SEAL INSTALLED BY GROUT BRAND NAME J j <br /> (? MOIIITwin GROUT SEAL PUMPED: A Yes (] No CONCRETE PEDESTAL BY DRILLER:)<Yes D NoyiJ <br /> Apmax.mm Z 6 t: LOCKING CHESTER BOX/STOVE PIPE r� <br /> Popum CBNTOBCTNBTMMLUN METHOD: MUD ROTARYZ AIR ROTARY_ AUGER_ CABLE_ OTHER_ <br /> I hereby cart Ify that i have pralWed thla application and that the work will be done in accordance wlth San Joaquin County Ordinsnces,� <br /> State law, and Rules and RqulatIOM of the San Joaquin County. Nowa owner or 'icanoed agent's signature cart ifies the following: al <br /> certify that in the perforNAMt of the work for which this permit is issued, 1 shall not employ persons subject to WORKMAN'S CONDENSATION c= <br /> law of plifgrnia.a Contractor's hiring or sub-contracting signature Certifies the following: " 1 certify that in the perforxmnco <br /> of the work for Nhieh this permit is issued, I shall etpl0y persons SubjOct to YORKMAN'S CONVERSATION law of California.' THE AY/IICAR -- <br /> MST Gil 14 NIMBLY 1 AAgVANCE NB ALL MWKT N AT Me M1-SU3. Complete drawing at lower area provided. <br /> Sighed X �`GAD �r/r+. Title QWAT- Date <br /> PLOT PLAN (Orem to Scale) Scale • to <br /> 1. sa of streets or roods nearest to or bonding the property. 4. Location of house sewage disposal system or <br /> 2. Outlins of the property, giving dimensions and North direction. proposed expansion of sewage dis30mal systems. <br /> 3. Dimensioned ewt(lnes ad location of all ox(sting and proposed S. location of wells within radius of TSO ft. on <br /> structures, including covered areas such as patios, driveways, the property or adlolning property. <br /> and"elks. <br /> C Is <br /> D <br /> N OA lJ1 C N Y <br /> NO <br /> P i1 0 J,Si ;i <br /> DEPARTNINT NSE ONLY <br /> � Data Z 1 Area�t"' <br /> ApPI(cation AcceptedBy ` _ <br /> Grout Inapectten IY/ /� ^-{� Date L/ 1 nwp Inspection ay Date,Y <br /> Destruction Irewtion By Dato Conwents: <br /> WMIM <br /> FACO <br /> #NTTIB EC[ BN iICNrE1 IV BATE Plami/ERWCE REOYEST BNrIER IOWSON <br />