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APPLICATION FOR WELLIPUMP PERMIT <br /> eee"1 JOAQUIN COUNTY PUBLIC HEALTH SERVICL... <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 ISSUEDM �6 <br /> ICempl/te in TOP11COW <br /> APPLICATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS AFPUCATION 18 MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TRUE,CHAPTER 9.1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSMR APN/ GG /` CITY A//L/L�f PARCEL SIZE/APN/ <br /> OWNER'S NAME / Y- C ( ADDRESS l�� ,l rir_ NE* /W) <br /> CONTRACTOR - -/�/JY//' �/1/O/ ��7. ADDRESS .JC It /.I �[/� lr� UC/ / 1�5 PHONE 0 <br /> BUB CONTRACTOR --�� ADDRESS - UCL/�1 - yy .III ONE/ <br /> TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL/ �bTHEq //[�J U/LUL- (�J /I A.L(•;�� <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL <br /> ❑Nsrvflbkepplr H.P. DEPTH PUMP SET_FT. FIRST WATER LEVEL <br /> TTYPE OF PUMP <br /> ❑ OUTIO -SERVICE WELL ❑ GEOPHYSICAL WELL/ ❑ SOIL BORING <br /> ' ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ( ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING 0 <br /> ❑ DOMESTIC/PNVATE ❑GRAVEL PACKISIZE TYPE OF CASINWSTEELJPVC EDA.OF WELL CASING D <br /> ❑ PUBUCBAUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION N <br /> ❑ IRRIGATION/AG ❑OTHER GROUT MAL INSTALLED BY GROUT BRAND NAME E <br /> 111 <br /> IJ MONITORING GROUT SEAL PUMPED: ❑Y. [IN. CONCRETEPEDESTALBYDWUJ:R:❑Y. [IN. S <br /> I APPNOX.DEPTH LOCKING CHESTER BOXWOVE RPE 5 <br /> r PROPOSED CONSTRUCTION/OWRING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW 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 WOR(FOR WHICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' COWRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERI'IFIE <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS O <br /> CALIFORNIA.- THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12081449411422. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Blyma X Title Dm <br /> PILOT MN IDra to Bolo)Scale 'to 'f <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR POPOSED Rl <br /> 2. OUTLINE OF THE PROPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL.SYSTEMS. <br /> J. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,D VEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. s- <br /> �.1 eR "F 15r LEST . <br /> ri <br /> �'PN IUAt11.1111 ( t I JIr � f, � / <br /> - o <br /> DEPARTMENT USE ONLY <br /> Application Accepted By t Det. Arse <br /> Grow ImpecUon By Dote Pomp Impectlon By T Date Y J <br /> D.tructlon Impeotion BY Data <br /> CommeMa; <br /> ACCOUNT-.ONLY: AID/ FAC/ <br /> PE CODES FEE INFO AMOUNT REMITTED NEC ABN RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> y5. �k 17O <br />