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APPLICATION FOR INELL►PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 388,304 EAST WEBER AVENUE,STOCKTON,CA 95201388 <br /> (209)408.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (ComplBte M TTipDetlJ) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FORA PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH E <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTERS-1 115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTYLIC AI�SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRElo SSIOR APN ✓ CITU C C.(/G L-� PARCEL SIZE/APNI <br /> OWNER'S NAME ADDRESS PHONE i <br /> CONTRACTOR ADDRESS LIC/ PHON RD- ` '(. <br /> 2YK <br /> SUB CONTRACTOR7E— 'h r✓.!' � �(y,/-Q ADDRESS 7 -�St.. aL_�LK;J IK <Lf PHONES <br /> I S' <br /> ( TYPE OF WEuAymp: ❑NEW WELL ❑REPLACEMENT WELL ,i`J-MONITORING WELL J� 7 ❑OTHER <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR /❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL J <br /> ❑N—❑R.p.Ir H.P. DEPTH PUMP SET Ff. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> ❑OLTT-OF-SERVICE WELL ❑GEOPHYSICAL WELL/ ❑ SOIL BORING <br /> ❑DESTRUCTION: <br /> INTENDED Un TYPE OF WELL , CONSTRUCTION SPECIFICATIONS <br /> ❑INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING <br /> ❑DOMEBTIC/PRIVATE �1RA-L PACKMIZE TYPE OF CASING/6TEEL/PVC 7" PVL DIA.OF WELL CASING <br /> O PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> ❑IMIGATIONIAG ❑OTHER �+ GROUT SEAL INSTALLED BY.,!! � GROUT BRAND NAME <br /> MONITORING 1`� GROUT SEAL PUMPED:❑Yr [IN. CONCRETE PEDESTAL BY DRILLER:❑Yw ❑N. <br /> APNIOX.DEPTH t LOCKING CHESTER BOX/STOVE RPE <br /> PROPOSED CONETRUCTION/dt1WNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> ]HE REBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES A <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:-1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHI <br /> THIS PERMIT IB ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.*CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIF <br /> THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS <br /> CAL1Fo THEA POCANT M�WT CALL t4 NOU1S IM ADVANCE FOR ALL REGNRED INSPECTTION$AT t"*)AMJJSII.C MPLETE OMWINO AT LOWER AREA PROVIDED. /�/ <br /> sl..,.d <br /> ATA <br /> 4-//a`/ III. +tE• !�"1+t7 It rS7 Dee. �� //7 <br /> PLOT PIAN IDR to B¢J.)We 'to <br /> t.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> z.OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3.DIMENSIONED OUTLINF.6 AND LOCATION OF ALL EXISTING AND PROPOSED S.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> ............... .i.....n......... ..:.......... <br /> " ..F ...i......;... ..... <br /> ...`,.. .... i. i....'... <br /> ' <br /> ......:......:....i.......................t... <br /> ..:....,y....... .............. .. <br /> ..: ....i.......'.....j............:.....:... <br /> ..j.....: ....`......:.. <br /> l ..........:.............:.............:............... _ .. <br /> DEPARTMENT USE ONLY �j <br /> Applic.tlon Acepted BY_�Cj'�'"�^' D.ee -[ Ara• L•t7•�.. <br /> Greet Impwlon By D.te Pump Inp.cll—By D.l. <br /> Datru 0-Inp.ction By D.e. <br /> Cemm.,t.: N1,Ll� <br /> ACCOUNTING ONLY: AIDI FACT <br /> PE CODES FEE INFO AMOUNT REMITTED C CK/CMN RECEI—BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> 00 0 13 7 S� <br />