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APPLICATION FOR WELL(PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION �LIr n_ ' �O LJ)M <br /> P 0 BOX 388,445 N.SAN JOAQUIN ST.,STOCKTON,CA 96201.388 �C U <br /> (209)4683420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (GmpYu in Triplicate) <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 Health Division. pct l ,S, F{I, CV <br /> Job Address/or APN# {�� Y a- Parcel Size)/.A/P�N# 7� <br /> Owner's Name ress r ��Ph'0 e 0,05 a�7�.J(J <br /> CDrtracto Address O Lic#_S��[ Phone # 1`"[ <br /> Sub Contractor Address Lic# Phone 0- <br /> TYPE OF WELL/PUMP: EN WELL 04EPLACEKENT WELL (IMONITORING WELL # (I OTHER <br /> ESTRUCTION [I OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL # ❑ SOIL BORING <br /> INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL # <br /> [I NNe�w��[I Repair N.P. DEPT-HH PUMP SET�J. _ FIRST WATER�LEVEL <br /> (TYPE OF PUMP) [/�t[/q'L L'e-t-'I � C?"��vl ---L c'P {C)/ <br /> INTENDED USE TYPE 0CONSTRUCTIONS CIFICATIDNS 48Y ) <br /> ❑ INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WELL EXCAVADIA. OF CONDUCTOR CASING-[I DD/OMESTIC/PRIVATE •GRAVEL PACK/SIZE TYPE OF CASING/STEEDIA. OF WELL CASING <br /> A}/PUBLIC/MUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEALSPECIFICATION❑ IRRIGATION/AG [I OTHER GROUT SEAL INSTALLEGROUT BRAND NAME <br /> [I MONITORING GROUT SEAL PUMPED: p(Yes [I No CONCRETE PEDESTAL BY DRILLER: [I Yes KNo <br /> APPROX.DEF T1 <br /> LOCKING CHESTER BOX/STOVE PIPE <br /> c <br /> PROPOSED CDNSTRUCTIONIORILLING METHOD: MUD ROTARY_AIR ROTARY_AUGER_CABLE_OTHER_ <br /> C7� <br /> I hereby certify that 1 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: "I <br /> certify that in the performance of the work for which this permit is issued, I shall not employ persons subject to WORKMAN'S COMPENSATION <br /> Laws of California." Contractor's hiring or sub-contracting signature certifies the following: " 1 certify that in the performance <br /> of the work for which this permit is issued, I shall employ persons subject to WORKMAN'S COMPENSATION Laws of California." THE APPLICANT <br /> MUST CALL 2=11011ANCE F,R A REQUIRED INSPECTIONS AT(201)488-3423. Complete drawing aAA-11/ <br /> r area provided. <br /> Signed X Title _ Date `'� <br /> PL 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 systems. <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 /> µr . <br /> eDAVri R t <br /> L cf{ <br /> IU1. 6 11W <br /> P LV—IR HEA H s m,I Es <br /> IR N TAS HEA TH Vf5 N <br /> DEPARTMENT USE ONLY �W Y <br /> Application Accepted ff\\ Date ` Aree <br /> Grout Inspection 8y Date <br /> .��V C a � Pump Inspection By Date <br /> D s tion s ct In By R '' �" '�'\ Date I't1 Comments: T� <br /> AE� NG41fLY: v AID# F ;& <br /> PE CODES FEE INFO AMOUNT REMITTED I CH CK ASH I RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> 4-�6 ooh a tt- C� o4oa <br /> o q v `' <br />