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APPLICATION fUR VYLLLIPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> L P 0 BOJ(388, 445 N.SAN JOAQUIN ST, STOCKTON,CA 9920133/ <br /> 12091 468-3420 <br /> _ NON REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> Pu t. r (CanPles I.Tnylimbl <br /> was Application Is here by made to the Sen 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 ed the Standards of Son Joaquin Canty Public Health <br /> Services, Ensirormentel Health Division. L/ n <br /> Job AEdresa/or APNN �yv0'v z: R• y x City z:^ t Parcel Site/APNN <br /> Address Phone S <br /> 6- Owner's Name ,/ <br /> Contractor Address LMN '�2ZFd Phone N6a+-�—•--•—�I <br /> Sub Contractor Address Lich Phan N <br /> V <br /> TYPE OF WELL/"P: [7 NEW WELL D REPLACEMENT WELL IT MONITORING YELLS [I OTHER <br /> D DESTRUCTION D OUT-OF-SERVICE WELL [I GEOPHYSICAL WELL N D SOIL BORING <br /> IT INSTALLATION 9 WELL SYSTEM REPAIR [I CROSS-CONNECT REPAIR D VAPOR EXTRACTION WELL S_ <br /> [I New ,q Repair X.P. � DEPTH PIIMP SET /fYEP6 FT. FIRST WATER LEVEL/K'/0 <br /> (TYPE OF PUMP) - <br /> INTENDED USE TYPE DF WELL CONSTRUCTION SPECIFICATIONS <br /> D INDUSTRIAL [I OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING <br /> [I DOMESTIC/PRIVATE [I GRAVEL PACK/SIZE_ TYPE OF CASING/STEEL/PVC DIA. OF WELL USING <br /> D PUBLIC/MUNICIPAL D DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> [1 IRRIGATION/AG [1 OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> 1 <br /> [1 MONITORING GROUT SEAL PUMIEU: D Yee 11 No CONCRETE PEDESTAL BY DRILLER: D Yes U NO-9 <br /> _ O <br /> AFPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE Q <br /> PROPOSED COYSTRUCTIOMIDRILLING METHOD: MUD ROTARY_AIR ROTARY_AUGER_CABLE_OTHER_ T <br /> 1 hereby certify that 1 have prepared this application and that the work will M done in accordance with Sen Joaquin Canty Ordinances, <br /> Laws, and Rules and Reguletions of the Sen Joaquin County. Home ver or licensed.Bre certifies to following: •1 <br /> Owner ent's signatuZ <br /> certify that in the perforronce of the work for which this permit is issued, I shall not employ persona Subject to YOIKKAN'S LTYPENSATIOI O <br /> Laws of California.* Contractor's hiring or Sub-contacting signature certifies the following: • 1 certify that in the performance C <br /> of the work for which this permit is issued, 1 shall employ persons subject to NOMOGRAMS COMPENSATION Law of California.• THE APPUCANT�- <br /> WHY CALL S4 ADVANCE FOR AL}�1EDUIRE SPECTIONS AT ass)UN423. Complete drawing at lower area provided. <br /> Title S Dati <br /> Signed%���o4n ��. <br /> PLOT PUN (Draw to Scale) Scale_• to <br /> 1. Names of streets or roads nearest to or banding the property. L. 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 ell existing and proposed 5. Location of its within radius of 150 ft. on <br /> structures, including covered areas such as patios, driveways, the property or adjoining property. <br /> and walks. <br /> iA <br /> t <br /> DEPARTMENT USE ONLY / <br /> Application Accepted By i< I'C YU��� D Ar«I2�/ <br /> Gran Inspection By Date Pump Inspection By oats( /S <br /> Destruction Inspection By Date Comments: <br /> ACCOUNTING ONLY: AID# FAC# <br /> ' PE CODES FEE INFO AMOUYT REMITTED HEC% CASH RECEIVED BY GATE PERMIT)SERVICE REQUEST NUMBER ovoicE <br />