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APPLICATION FOR WELLIPUMP PERMIT <br /> �.-USAN JOAQUIN COUNTY PUBLIC HEALTH SERV,,, <br /> ot ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 446 N. SAN N ST., STOCKTON, CA 8620i•388COPY <br /> (209)209) 46488.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (ctmpltm M Triplicate) <br /> APPLICATION IB HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOM DESCPoBED.THIS APPUCATION IS MADE IN COMPUANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE CHAPTER 8-`1x116,3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> ,I,/ <br /> JOB ADDRESSOR APNP �y'0 W PJIA lll/I CT' A i LI PARCEL SQE/APN/'FJ4/F,//+✓I <br /> OWNER'S NAME F ADDRESS w PHONE I_y1�,AJT <br /> CONTRACTOR ADDRESS (�� 1 �n/. I LICK PHONE I••77 <br /> SUB CONTRACTOR ADDRESS UCS RHONE S <br /> TYPE OF WELLMUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITONNG WELL I__ ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELLi J <br /> ❑Now❑R.p. H.P. DEPTH PUMP S17—FT. FIRST WATER LEVEL O <br /> STYPE OF PUMP) <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL E ❑ SOIL BORING B <br /> ❑DESTRUCTIONS. <br /> INTENDE E TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> USTRIAL <br /> 1 ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING A// '" O <br /> ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEUPVC DIA.OF WELL CASINO O L <br /> Cl PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION M A <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY wiw ( GROUT BRAND NAME III/ ' I1••1 E <br /> ❑ MONITORING �� A 1 GROUT SEAL PUMPED: ON. CONCRETE PEDESTAL BY OLSLLE&13,V* El No S C <br /> APPROX.DEPTH I� / LOCKING CHESTER BOX/STOVE RPE S. <br /> W WETCS <br /> PROPOSED CONSTRUCTION/DNG 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 LICENSED AGENT'S SIGNATURE CERTIFIES THE F0l10WING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT 16156UED,ISH NR PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE CALIFORNIA.I�CI NTAq, TL 121� R�6A1 E OF THE WOW FOR VANCE FOR ALL RFRU la I 1 Y1�cICH THIS PERMIT{/T6UEAlL�MPUDY� TR PERSUBJECT TO WOFtKMAN'$SONS <br /> AT LOWER DARPROVIDED. <br /> tATIOy WS OF <br /> A 76 <br /> PLOT RAN Mr.w to SCM.)Sulo to <br /> I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SV OR RIOPOSED <br /> 2, OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> G. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALLS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> lit- <br /> � TA <br /> C <br /> DEPARTMENT USE ONLY (� C <br /> Appliwtlon AooWW BY Date d ' ) A,.. _ <br /> Grout In tion BY D.bl-1 —95 P.P Inp.etim By Mt. <br /> D..tru.tlon ImImatlon BY ��I (�/� J� De. �/I� <br /> Gpmmanb: `1 So�c�I� <br /> milk '�, f Lc".Q , S rt, /�/"1- gro p 2u' '-f O k. VF-/ <br /> CCOUNTINO ONLY: AIDI FAC/ <br /> PE CODES FEE INFO AMOUNT REMITTED XECNA ASH RECOVED BY I:jDATE PERMIT/SERVICE REQUEST NUM6ER INVOICE <br /> `� a. 4L6g!a s 0,�„?333 <br />