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APPLICATION FOR WELLJPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 398, 446 N. SAN JOAWIN ST, STOCXTON, CA 96201.388 <br /> (209) UB-3420 <br /> NOWIl FUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> iCompieta IN Tripkatsl <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 co plionce with San Joequin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Publfc Health <br /> Services, Environmental Health Division. n / <br /> Job Address/or APN#J ?2 7 S rAR"�y City gjj` Parcel Size/APN# "IVA(,p-5-- <br /> Owner's <br /> Owner's Name22gA/ AZZ 10 le,/G Address_ Phom #3—? ,.�, <br /> Contractor ,i7Q!`1Jit/G 7VCAddress X00 S- I<lLg& no #tyi ` 1 . <br /> Sub Contractor Address Lic# Phone # <br /> TYPE OF HELL/PUMP: �tNEH WELL [I REPLACEMENT WELL [] MONITORING WELL # [1 OT!IER <br /> [1 DESTRUCTION [] OUT-OF-SERVICE HELL 11 GEOPHYSICAL WELL # [1 SOIL BORING <br /> [1 INSTALLATION 11 WELL SYSTEM REPAIR [I CROSS-CONNECT REPAIR [1 VAPOR EXTRACTION WELL #_ J <br /> [] New [1 Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL _ <br /> (TYPE OF PUMP) <br /> C <br /> INTENDED USE TYPE OF WELL CONST OCT) SPECIFICATIO <br /> rr 1 <br /> [1 INDUSTRIAL [1 OPEN BOTTOM DIA. OF WELL EXCAVATION / //ti/- DIA. OF CONDUCTOR CASING <br /> [I DOMESTIC/PRIVATE 'A GRAVEL PACK/SIZE_6 TYPE OF CASING/STEEL/PVC_f VC DIA. OF WELL CASING <br /> (] PUBLIC/MUNICIPAL (1 DRIVEN DEPTH OF GROUT SEAL )Z7- SP CIFICATIOM <br /> IRRIGATION/AG 11 OTHER GROUT SEAL INSTALLED BY C'�4497&X!ka I&T BRAND NAME�,f/D <br /> (1 M)IIITOR ING GROUT SEAL PUMPED: '?,Yes ❑ No CONCRETE PEDESTAL BY DRILLER: [I Yes [1 No r <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE— <br /> PROPOSED CONSTRUCTIONIDRILLING METHOD: HUD ROTARY__ AIR ROTARY_ AUGER` CAF.LE_ OTHER_ <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 Joaqu n County. Home owner or licensed agent's signature certifies the following: "f <br /> certify that in the performance of the work for which this permit is issued, : shall not employ persons subject to WORIOIAN'S COMPENSATION <br /> Laws of California." Contractor's hiring or subcontracting signature certifies the following: rr I certify that in the performance <br /> of the work for which this permit is issued, I shat( employ persons subject to WORKMAN'S COMPENSATION Laws of California." THE APPLICANT <br /> MUST CALL 24 H IN �:IDVCI FOR L REQUIRED INSPECTIONS AT 12!!21 458.3423. Complete drawing at L or area provided. <br /> Signed X Title Dat <br /> y <br /> LOT PLAN (Draw to Scale` Scale " to <br /> 1. Names of streets or roads nearest to or bounding the properxy. 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 praposed 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 /> O <br /> L <br /> } 'Qll I 'N' <br /> 16-61 <br /> E , <br /> I <br /> DEPARTMENT USE ONLY �� <br /> Application Accepttd By Dat e 'S 1 7 �_ Area Z!R <br /> Grout Inspection By <br /> ate Pump Inspection By IDate <br /> Destruction Inspection By____Z Date Comments: <br /> ACCODUTiNB QALY: AID* FACM 5LD A 00 �� \ <br /> PE LADES FEE INFO AMOUNT REMITTED :CHECKYICASH RECEIVED BY DATE PERMITISERInCE RE `C� <br />