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APPLICATION FOR WELLIPUMP PERMIT` <br /> QAN JOAWIN COUNTY PUBLIC HEALTH SERVIC <br /> ENVIRONMENTAL HEALTH DIVISION �. <br /> P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201.388 <br /> (209) 468.3420 <br /> W NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED_. ,"-, _ <br /> (Cemplate M Tripliests) <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 compliance with San Joaquin County Development Title, Chapter 9-1115.3 and the standards of San Joaquin County Public Health <br /> Services, Environmental Health Division. � 1 <br /> . <br /> 1� � `� City Parcel Size/APN# <br /> Job Address/or A L J� �,qt( <br /> Owner's Now s <br /> Address` 1 E_ -�i SAA�tA Phone nYam/I/_/_ <br /> Contractor t- ----'-Addresg _ Lic..- Phone <br /> S� 1 ( il Addressol3(ps��l�(AYlvY4 Lic# �(ao2�P�i_- � <br /> :Phone #aq6,5=g7[)- <br /> s�1T Contractor - <br /> t1 TYPE OF HELL/PUMP: Y NEW WELL [7 REPLACEMENT WELL 0 MONITORING WELL # CI OTHER <br /> j - E7 DESTRUCTION C7 OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL # [7 SOIL BORING `�Ja <br /> \e`1( '( INSTALLATION C7 WELL SYSTEM REPAIR [7 CROSS-CONNECT REPAIR [7 VAPOR EXTRACTION WELL O <br /> [7 New C7 Repair X.P. DEPTH PUMP SET FT. FIRST MATER LEVEL L'106 g�Ug <br /> (TYPE OF PUMP)P) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> u <br /> [7 INDUSTRIAL 0 OPEN BOTTOM DIA. Of WELL EXCAVATION DIA. OF CONDUCTOR CASING <br /> [7 DOMESTIC/PRIVATE 1$ GRAVEL PACK/SIZE 2. 1Z TYPE OF CASING/STEEL/PVC DIA. OF WELL CASINGf1 <br /> [7 PUBLIC/MUNICIPAL 0 DRIVEN DEPTH OF GROUT SEAL_ 4/11SPECIFICATION <br /> © 0 IRRIGATION/AG E7 OTHER GROUT SEAL INSTALLED BY D%Agelr- GROUT BRAND NAME <br /> ,MONITORING -70 GROUT SEAL PUMPED: b�Yes 0 No CONCRETE PEDESTAL�BY1 DRILLER: 17 Yes [7 No <br /> APPROX.DEPTH ,4LOCKING CHESTER BOX/STOVE PIPEb1161, rkA itf, L[?LLILit�' iN4. <br /> PROPOSED CONSTRUCTIONIDRILLIMG METHOD: MUD ROTARY_ AIR ROTARY_ AUGERXC CABLE_ OTHER_ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Canty Ordinances, <br /> State Laws, and Rules and Regulations of the Sen Joaquin County. Hone owner 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 C014PENSATION <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, I shall employ persons subject to WORKMAN'S COMPENSATION Laws of California." THEAPPLICAMT <br /> MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT(202)468-3423. Complete drawing at Lower area provided. <br /> , <br /> Sig Title 00 Date <br /> t <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 systems. <br /> 3. Dimensioned outlines and location of all existing and proposed 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 /> a+ Wx. x zl <br /> I LU <br /> x <br /> z <br /> � 1 - <br /> s <br /> W " W <br /> x�—x YY x x <br /> ( DEPARTMENT USE ONLY <br /> Application Accepted ^B'y7-n p�C~Fy Date "�"�—Kra <br /> �- Grout Inspection By Date t'O� �� /✓ Pimp Inspection By Date <br /> Destruction Inspection By Date Comments: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> 0 8az0 �fk3.5 <br /> t <br /> r <br />