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APPLICATIN FOR t7ELLIPUMP PEKmIT <br /> SAI JOAQUIO COMITY PUBLIC HEALTH SERVICES <br /> EOVIROOMEMTAL HEALTH DIVISIOU <br /> P 0 BOX 380,446 I.SAM JOAOUIU ST,STOCI(TOO,CA 86201-M <br /> (208)460.3420 <br /> D 11011-REFUCDABLE PERL'.IT EXPIRES 1 YEAR FDOtl DATE ISSUED <br /> (Cacpl3b In Tr4Eastal <br /> Application is here by mace to the San Joaquin County for a permit to construct and/or install the work described. This application is <br /> mode in compliance with Sen Joaquin County Development Title, Chapter 9-1115.3 and21'e— <br /> tandards of San Joaquin County Public Health <br /> services, Environmental wealth Division. <br /> ��// �f <br /> Job Address/or APN# �� iCYr/ �c iii City Z."^ Parcel Size/APN# <br /> Owner's Nara o Le P Address Phone# <br /> Contractor Address2V? dcj<'Lic# DC) Phone #S�a <br /> Sub Contractor Address Lic# Phan # <br /> TYPE OF WELL/PUMP: [I NEN WELL 11 REPLACEMENT WELL 11 MON17ORING WELL # [I OTHER <br /> ❑ DESTRUCTION [1 OUT-OF-SERVICE WELL p GEOPHYSICAL WELL # 11 SOIL BORING <br /> S n [1 INSTALLATION A WELL SYSTEN REPAIR (I CROSSCONNECT REPAIR 11 VAPOR EXTRACTION WELL # <br /> 11 New A Repair X.P. DEPTH PU* SET FT. FIRST WATER LEVEL/400 <br /> (TYPE OF PICP) <br /> 17TEM0111 USE TYPE OF WELL COUSTRUCTIOC SPECIFICATIODS <br /> [I IKWSTRIAL [I OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING <br /> [I DOMESTIC/PRIVATE ❑ GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC 01A. OF WELL CASING <br /> [1 PUBLIC/MUNICIPAL (I DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> [) IRRIGATION/AG [I OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> 11 MONITORING GROUT SEAL PUMPED: [7 Yes ❑ No CONCRETE PEDESTAL BY DRILLER: 11 Yes [I M0-4� <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE o <br /> PROPOSED COCSTRUCTIOCIORILLICO UETHOD: MUD ROTARY_AIR ROTARY_AUGER_CABLE_OTHER_ <br /> m <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Sen Joaquin County Ordimmricas, <br /> State Laws, and Rules and Regulations of the San Joaquin County. Now owner or licensed agent's signature certifies the.following: 9 <br /> certify that in the performance of the work for which this permit is issued, I shall not employ persons subject to WORIIAN'S COMPENSATION <br /> Laws of California." Contractor's hiring or sub-contracting signature certifies the following: " I certify that in the performance <br /> of the work for which this permit is issued, 1 shall amploy persons subject to WORKMAN'S COMPENSATIOU Laws of California." THE APPLICACT—r" <br /> COST CALL 24 NH ADYACCE FOR AL EQUIRE SPECTiOCS AT(201)4C$3423. Complete drawing at lower area provided. <br /> Sigrid X / �/� Title Dateo- <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 system. <br /> 3. Dimensioned outlines and location of all existing and proposed 5. Location of wells within radius of 150 ft. an <br /> structures, including covered areas such as patios, driveways, the property or adjoining property. <br /> and walks. <br /> 01 <br /> DEPARTLIECT USE CELT <br /> Application Accepted By Area L2ii �I <br /> Grout inspection By Date Pump Inspection By Date!C/ <br /> Destruction Inspection By Date Comments: j <br /> ACCOUWICB OCLY: AID# FAC# <br /> PE CODES FEEE/ICFFOO ACOUDET REUITTED CASH RECEIVED BY DATE PERMFTISERVICE AEOUEST DUCBEA CIVOICE <br /> 52©ao <br />