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APPLICATION FOR WELLIPUMP PERMIT # <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERV <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 86201=3BS`,Y)1—� <br /> .(209).488-3420 <br /> HEAL a <br /> i ,'�': � t <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . � t�' <br /> (Complete is Triplicate) •� � j pi� <br /> Application is here by made to the San Joaquin County for a permit to construct and/or install the work descrif= <br /> made in compliance with San Joaquin Count Development � > aPu€lic Hea is f! <br /> q y pment Title, Chapter 9-1715.3 and the Standards of San Joaquin County Public Health <br /> Services, Environmental Health Division. � <br /> Job Address/or APN# city Parcel Size/APN# 5 <br /> Owner's Name Phone # 3 <br /> Contractor ���I'Jr//r ��_,z�s k <br /> /lldNr�ss�d4'a <br /> 6Q, Lick -Z Phone #956'Q Zo <br /> Sub Contractor Address Lic# > Phone # <br /> TYPE OF WELL PUMP:, [7 NEW WELL [] REPLACEMENT WELL 0 MONITORING WELL # [] OTHER <br /> S I <br /> [] DESTRUCTION ❑ OUT-OF-SERVICE WELL [7 GEOPHYSICAL WELL # SOIL. BORING rd ll 3 -3 <br /> [] INSTALLATION [7 WELL SYSTEM REPAIR [] .CROSS-CONNECT REPAIR C] VAPORi1EXTRACTION WELL # <br /> [] New 0 Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE Of WELL CONSTRUCTION SPECIFICATIONS <br /> 0 INDUSTRIAL [7 OPEN BOTTOM DIA. OF WELL EXCAVATION 'i DIA. OF CONDUCTOR CASING,//` <br /> [] DOMESTIC/PRIVATE [7 GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC /01,4 DIA. OF WELL CASING <br /> [7 PUBLIC/MUNICIPAL [7 DRIVEN DEPTH OF GROUT SEAL SPECIFICATION r /� <br /> 0 IRRIGATION/AG [] OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> /kIlMONITORING ' GROUT SEA! PUMPED: [7 YesNoCONCRETE PEDESTAL'.BY DRILLER: [7 Yes [] No + <br /> APPROX. DEPTH LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTRUCTGONrDRILLiNG METHOD: MUD ROTARY_ AIR ROTARY AUGER_ CABLE_ OTHERv�-y <br /> I hereby certify that I 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. Homeowner 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 certifythat in the performance <br /> of the work for which this permit is issued, I shall employ persons subject to WORK14ANIS COMPENSATION Laws of California." THE APPLICANT <br /> MUST CALL 2M"OIM DVA FOR ALL REOU RED INSPECTIONS AT(209)468.3423. Complete drawing at lower area provided. <br /> Signed X Title <br /> ��� iDate /�L <br /> PLOT PLAN (Draw to Scale) Scale " to� i <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 theiproperty, 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 i <br /> structures, including covered areas such as patios, driveways, the property or adjoining property. , <br /> and walks. f <br /> tz <br /> i3 <br /> .6 <br /> iy <br /> I4 <br /> !i <br /> a <br /> :i <br /> 4 <br /> DEPARTMENT USE ONLY- ,t <br /> Application Accepted By Date ''!�� Area <br /> { <br /> Grout Inspection By Date Pump Inspection By Date ii <br /> Destruction Inspection By Date Comments: <br /> ACCOUNTING ONLY: AID# FAC# <br /> t <br /> PE CODES FEE'INFO AMOUNT REMITTED CHECKACASH RECEIVED BY DATE PERNIT(SERVICE REGUEST NUMBER INVOICE <br /> JDI � �Z� �•Z]c• D r7 ` <br /> r <br /> f? <br />