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APPLICATION FOR WEL PUMP PERMIT <br /> SAN JOAQUIN COUNTY PLIBUC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, ST CKTON, CA 95202 <br /> (209)468-3420 <br /> ' RON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Cempkis IR Trip ata) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADOREBBAOR APNE LAX J CITY PARCEL B1ZE/APN/ <br /> OWNER'S NAME ADDRESS a I PHONE# <br /> ^ A f <br /> CONTRACTOR �-P� - ADDS <br /> RES LIC# PHONNE/I <br /> SUBCONTRACTOR ADDRESS CI ZZ7 PHO' NE'I <br /> 82�=�m V— <br /> TYPE OF WELVPUMP: ❑ NEW ❑ REPLACEMENT WELL ❑ MONITORING <br /> WE <br /> LL# ❑ OTHER <br /> NSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECr REPAIR ❑ VAPOR EXTRACTION WELL# J <br /> ❑New❑Repm, H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> fiVTE OF PUMPI <br /> ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL VIELL N 9 SOIL BORING S <br /> ❑DESTRUCTION: <br /> INTENDED VEE TYPE OF WELL CONSTRUCTION SPECIFICATION 9. Q <br /> © INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 1l DIA,OF CONDUCTOR CASINO D <br /> ❑ DOMESTIC/PW VATS ❑GRAVEL PACKIBIZE TYPE OF CASINO/STEELJPVC OVA.OF WELL CASINO D <br /> ❑ PUSLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL I SPECIFICATION R <br /> ❑- VOD-ATIONIAG (3OTHER GROUT SEAL INSTALLED BY A GROUT BRAND NAME E <br /> �MONRORINti � GROUT SEAL PUMP CHESTER ASTER OXISTOVE PIPE CONCRETE PEDESTAL SY DR -❑ILLERYrt ❑Ne s <br /> APPROX.DEPTH <br /> PROPOIFJ)CONITRUCTIONMRIL11NG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE ptHER <br /> I HE9EDY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE N ACCOFIOANci WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS Of THE SAN JOAOUM COUNTY. HOME OWNER OR LICENSED AOENT'S SIGNATURE CERTIFrES TNI FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE Of THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,i SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTWO SIGNATURE CERTIFIES <br /> THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORIKMAWG COMPENSATION LAWS OF <br /> CALIFORNIA,' THE APPLICANT MUST CALL 24 HOURS,IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT <br /> AT DOST/aRf422. COMPLETE DRAWING AT LOWER AREA P"DWDEO. <br /> Slgrad x t {�L�/y"' TItI• -�--lv �+S On• .5 '� <br /> PLOT PIAN Prow to Saalol Boole •to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEM@. <br /> 3. DIMENSIONED OIfTLINF.B AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS V RTHIN RAONS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PAMS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY, <br /> 444 <br /> DEPARTMENT US!ON LY /1/�! ���" <br /> ApplleoHen Aoe•pted BY Date ` A.r` !"`r.a4--t �y— . <br /> Grout hwpeotl n BY vete Pc p Irnpeatlon III Dole <br /> Oeelnretlen Impeellon BY Date <br /> Comment•: <br /> ACCOIMTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHE6;?CA6H RECEIVED BY 10 ATE PEIMITISERVICE REQUEST NUMBER INVOICE <br /> aq.oI A0ir-5- s 4 Dl ? <br /> Pub Heafth Serv.-EnYiro.173(1197) <br />