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APPLICATION FOR WELLJPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201.388 <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 WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115 3 AND THE <br /> /STANDARDS OF SAN JOAQUIN CO2Y;'711 HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESS/OR APNI /I `SAl. ( lav `, CITY / (, /� PARC L SIZE/APNN <br /> OWNER'S NAME l //"��J/ ADDRESS al / ✓� 4PHONE <br /> T CONTRACTOR L E/'" ' DRESS �� // CR�PHONE I / L I V <br /> 1 / <br /> SUB CONTRACTOR L / ADDRESS 11!7// i f"���LICO ?r f PHONE <br /> TYPE OF WELLJPUMP: NEW WELL py REPLACEMENT WELL ❑ MONITORING WELL l' ❑ OTHER <br /> S ,/w<<s ❑ INSTALLATION /❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL• ✓ <br /> jaN—13I Repair H.P. DEPTH PUMP SFT &FT. FIRST WATER LEVEL O <br /> (TYPE OF PUMP) <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL Ir ❑ SOIL BORING B <br /> DESTRUCTION: / <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS / ,( J A <br /> ���❑-- INDUSTRIAL El OPEN BOTTOM DIA.OF WELL EXCAVATIO �L I DIA.OF CONDUCTOR CASING � D <br /> L]i DOMESTIClPRIVATE pp GRAVEL PACK/SIZE TYPE OF CASING/STE VC — DIA.OF WELL CASING L" D <br /> /❑-PUBUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL , SPECIFICATION / R <br /> ElIRRIGATION/AG El OTHER ' <br /> R GROUT SEAL INSTALLED BY /S GROUT BRAND NAME 0144 <br /> E <br /> ElMONITORING GROUT SEAL PUMPED: Yee ❑No CONCRETE PEDESTAL BY DRILL FR:wYee S h <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S <br /> PROPOSED CONSTRUCT1ON/DRIL11N0 METHOD: MUD ROTARY_L�IR 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,STATE LAWS,AND RULES AND <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 WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I C IFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'&COMPENSATION LAWS OF <br /> CALIFORNIA.' THE ANT MUB CA 24 HO URB IN ADVANCE FOR ALL REQUIRED INSPEC T(208)46034 COMPLETE WING AT LOWER AREA PROVIDED. <br /> Slpned X 71t1e <br /> PLOT PLAN(Drew to So Ie)Sule�_ <br /> 1. NAMES OF ST O ZADS N /ION <br /> O OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVINGSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCAF 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 /> Cl L9 9 _ _ 4VN <br /> a , <br /> �. v U) <br /> G- <br /> 06 <br /> _ <br /> . .. � To D SQ Cl w'� <br /> < hwz f i1x0'y a---o � /Cie <br /> �� _ AYMEN <br /> RFC: <br /> S <br /> JUN 1995 <br /> DEPARTMENT USE ONLY I L,,4vIF'n-NII (ENTAL HEALTH DjI /&,- <br /> AppBcetlon Accepted BY \ _ Oete-- --/- / K�_ Area <br />