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APPLICATION FOR WELLIPUMP PERMIT , <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 96201-388 <br /> (209) 4683420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplleste) <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 Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br /> Services, Environmental /, <br /> Health Division. ^ // n <br /> Job Address/or APN# —2z (J�'9 &A, �4SON /D City ��ry Parcel Size/APN# <br /> Nam F/c <br /> Owner's Nag/ 'f�00,V4 Address Z�5-V UP-0,644VA Phone <br /> Contractor CALJ.(/ � �7e/L1/1/�.�� Address L�r� S- 1Cl .(� c/ %/ (� ��J`��� phone # <br /> J <br /> Sub Contractor Address Lic# Phone # <br /> TYPE OF WELL/PUMP: [) NEN WELL [7 REPLACEMENT WELL [] MONITORING WELL # [] OTHER <br /> OZ DESTRUCTION [7 OUT-OF-SERVICE WELL (] GEOPHYSICAL WELL # [7 SOIL BORING <br /> [] INSTALLATION (7 WELL SYSTEM REPAIR (7 CROSS-CONNECT REPAIR [7 VAPOR EXTRACTION WELL # <br /> [] New [] Repair N.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) a <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS C1 <br /> ❑ INDUSTRIAL (] OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING <br /> (7 DOMESTIC/PRIVATE [] GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA. OF WELL CASING <br /> [7 PUBLIC/MUNICIPAL [7 DRIVEN DEPTH OF GROUT SEAL`) SPECIFICATION (}� <br /> [] IRRIGATION/AG [] OTHER GROUT SEAL INSTALLED BY LX--- GROUT BRAND NAME v <br /> 0 MONITORING GROUT SEAL PUMPED: [7 Yes [] No CONCRETE PEDESTAL BY DRILLER: 17 Yes [) N._L <br /> APPROX. DEPTH LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTRUCT IONIDRILLING 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 <br /> State Laws, and Rules and Regulations of the San Joaquin County. Home owner or licensed agent's signature certifies the following: <br /> certify that in the performance of the work for which this permit is issued, 1 shall not employ persons subject to WORKMAN'S COMPENSATI Ott) <br /> Laws of California." Contractor's hiring or sub-contracting signature certifies the following: 111 certify that in the performenc \' <br /> of MUST CALL 24 the work for which this permit is issued, I shall employ persons subject to WORKMAN'S COMPENSATION Laws of California." THE APPLICANT <br /> RS VAMCE FOR�A�LL REQUIRED INSPECTIONS AT (208)4883423. Complete drawing att tower area provided. <br /> Signed X �1�%N,WII�I Title <br /> PLOT PLAN (Draw to Scale) Scale to__ <br /> 1. Names of streets or roads 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 cyst <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 /> L/ <br /> 15 <br /> "am <br /> W <br /> F'I _ICEA IH ..- . .LLL <br /> DEPARTMENT USE ONLY <br /> c_ <br /> Application Accepted By Date�f1�,r�y_\..�'. Date Area <br /> Grout Inspection By Date Pump Inspection By Date <br /> Destruction Inspection By Date -2-'�S Camw!nts: p•�"""-'^-"' � 2?5 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED HECK CASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> sv D GS1 <br />