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APPLICATION FOR INELLIPUMP PERMIT <br /> SAN JOADUIN COUNTY PUBLIC HEALTH SERVICES <br /> "Nor" <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388,446 N.SAN JOADUIN ST,STOCKTON,CA 95201.388 <br /> (209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete M Triplicate) <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, Envirorment'att Health Division. <br /> tZ�7Job Address/or APN# `14Uy 21 <br /> l0 ,e City Ybel, t4 <br /> pparccel Size/APN# <br /> Owner's Nameg?UnAddre W3Z7 Phone <br /> e#� <br /> c <br /> l 1 1 G-P{wt r <br /> Contractor W00CkLC1, r1U ^ 0—kN1.2 Address r Lie# Phone # <br /> Sub Contractor SnOr Y(-llnM Address Ct)141410N41 [Gd1_lic# Phone # s gZIZ <br /> TYPE OF WELL/PUMP: 11 NEW WELL (1 REPLACEMENT WELL [1 MONITORING WELL # (1 OTHER <br /> X DESTRUCTION ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL # ❑ SOIL BORING <br /> (1 INSTALLATION (1 WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR [1 VAPOR EXTRACTION WELL # <br /> IT New (1 Repair N.P. DEPTH PUMP SET FT. FIRST W�[ER LEVEL <br /> (TYPE OF PUMP) 11 //_ ) _I_l 5"r /_ _ <br /> P�esst...�n a,fO�.T /�rt��0J T-0 D ?, S (I!+'+LP.�� '(D JC <br /> INTENDED USE TYPE OF WEII CONSTRUCTION SPECIFICATIONS <br /> [I INDUSTRIAL (1 OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING <br /> (1 DOMESTIC/PRIVATE [I GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA. OF WELL CASING <br /> ❑ PUBLIC/MUNICIPAL [1 DRIVEN DEPTH OF GROUT SEAL SPECIFICATION _ <br /> [1 IRRIGATION/AG (1 OTHER GROUT SEAL INSTALLED BYGROUT BRAND <br /> I) MONITORING GROUT SEAL PIMPED: [1 Yes (1 No CONCRETE PEDESTAL BY DRILLER:*Yes (1 No <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTRUCTIONIDRILLING METHOD: MUD ROTARY_AIR ROTARY_AUGER_CABLE_OTHER_ <br /> 1 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. Home owner or licensed agent's signature certifies the following: "1 <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 certify that in the performance <br /> of thewhich this permit is issued, I shell employ persons subject to WORKMAN'S COMPENSATION Laws of California." TNEAPPLICANT O <br /> MUST Cw LL 24 HO S IN ADVANCE FOR ALL REO IRED INSPECTIONS AT 1201)462-3423. Complete drawing at <br /> Lower area provided. <br /> Signed g Title <br /> PLOT PLAN (Draw to Seale) Scale " to J <br /> 1. Names of streets or roads nest 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 /> 11 <br /> Z <br /> PA <br /> MR <br /> AN OA' UIl• t;lJ <br /> is viANM NT 1L A A!. f?' <br /> DEPARTMENT USE ONLY <br /> i <br /> Application Accepted SY)iA Date-96 Area <br /> Grout Inspection By_— Date Pump Inspection ey Date <br /> Destruction Inspection By ��,.pete Comments: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED ECN ASH RftfJ1q9RY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> vp <br /> 502 ,OU � Z <br />