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• APPLICATION FOR INELLIPUMP PERMIT 46 <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOAQUIN ST, STOCKTON, CA 95201.388 <br /> (209) 488-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUED <br /> (Complete in TTgliUtB) i <br /> APPLICATION IS HEM BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WOR(DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AN/D—D THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSXR APN# �O —CITY PARCEL-SSLIZE/APNY <br /> �I <br /> OWNER'S NME W' b• ADDRESS 33LuSMV2I557LPHONNEE# <br /> / CONTRACTORII IYNI1OVI ADDRESS UV� wIfFWc�N'y �lF-F+'iIICI � <br /> - - A '�� NiSC1 PHONE•SUBCONTRACTOR �roweYnrwyl O <br /> �/—� O <br /> IL I'Lz II <br /> TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL# ✓ <br /> ❑Ne.,❑Re w' N.P. DEPTH PUMP SET—FT. FIRST WATER LEVELsk f' Ss <br /> ll O <br /> DYNEPE OF R1MP - <br /> ❑ OUi-0 ❑ <br /> OUT-OF-SERVICE WELL OEOPHVBICAL WELLI SOIL BORING \ B <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA,OF CONDUCTOR CASING D <br /> ❑ OOMESTICRHIVATE El GRAVEL PACK/SIZE TYPE OF CASING/BTEEIAPJC DIA.OF WELL CASING D <br /> ❑ PUBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION H <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITORING GROUT SEAL WMPED: [I Y. [I N. CONCRETEPEDESTALBYDRILLER:❑Y. ❑N. S <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE__ - <br /> 1 C( 3 <br /> PROPOSED CGNSTRUCTIONIDRWNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER Ll lv_J 1,_` <br /> re <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I 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 SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COM ATION LAWS OF <br /> CALIFORNIA.- THE APPRCAN1 M�WT�CAU,I HOURS IN ADVANCE FOR ALL REQUNIED({IINSSP�ECTIONS AT IZDS�I 411104=},.pCOMPLETE DRAWING AT LOWER AREA <br /> Slpmtl XTItl. P `�(�E-C� — ""/'`V D. <br /> PLOT PAN IDr.w m S .)5u1. 'w <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 SYSTEMS, <br /> 3. DIMENSIONED OUTLINES 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 /> nC Nb'R1 <br /> Fin 3 At "C)c <br /> o <br /> a5 <br /> g7 <br /> --r <br /> r�r <br /> DEPARTMEIIT USE ONLY <br /> Applb fi.n Ao w BY E 1 D.w `•��-T L� Nr O� L �/ <br /> Groh Impec6on By 0.'. Pump Impecllon By D.[. <br /> Del. <br /> D.nuc6on Imp.olbn BY <br /> Camm.nb: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE COOEII FEE INFO AMOUNT REMITTED CHECIUXASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> 0 Yw&vo <br />