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APPLICATION FOR WELLIPUMP PERMIT <br /> AN JOAQUIN COUNTY PUBLIC HEALTH SERVICE <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201.388 <br /> (2091468-3420 <br /> RON•REFUNDABLE PERMIT EXPIRES 1 YEAR FROU DATE ISSUED <br /> lComplato is Triplicate) <br /> A derintc n is here by de to the San Joaquin County t[nce with San Joaquin County Development oTitle,erChapter 9-1115.3 and/the Standards of San Joaquin County application <br /> t <br /> Public Health <br /> ma �+P <br /> Services, Environmental Health Division. <br /> c�/ N � Ja City Parcel Size/APN# <br /> Job Address/orrAPPN# 3 <br /> 7�fCjjGs Address(�G[/y �G�' / ne <br /> owner s Name_ S-k�� ccp B/y /� a���2 112 <br /> -,7—7` /O ' is 1;375�a�- Phone # <br /> Contractor // C� � � Address <br /> ^� �ISt7 {r�or..� x0c 4/y5/6'!r-phone # a �13-C13CY <br /> Sub Contractor �+���� Address �'/ate ��z�ys Lic# 07 <br /> M 4) <br /> TYPE OF WELL PUMP: [] NEW WELL [I REPLACEMENT WELL MONITORING WELL # M 'Z/y <br /> 3 OTHER <br /> DESTRUCTION Y OUT-OF-SERVICE WELL E] GEOPHYSICAL WELL # [I SOIL BORING <br /> X ,I <br /> [] INSTALLATION [] WELL SYSTEM REPAIR [I CROSSCONNECT REPAIR VAPOR EXTRACTION WILL #vow 8 <br /> [I New [I Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE­­OF CONSTRUCTION SPECIFICATIONS r N <br /> [] INDUSTRIAL [] OPEN BOTTOM DIA. OF WELL EXCAVATION r0 DIA. OF CONDUCTOR CASING <br /> [I DOMESTIC/PRIVATE [] GRAVEL PACK/SIZE TYPE OF CASING/STEEL VC a~�4'-S � DIA. OF WELL CASING �/� �-- <br /> [] PUBLIC/MUNICIPAL [] DRIVEN DEPTH OF GROUT SEAL V"-b/ SPECIFICATION -S'� yo <br /> [] IRRIGATION/AG [] OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME b ~ <br /> X MONITORINGLOCKING CHESTER BOX/STOVE PIPE u'&L (o30ff � GROUT SEAL PUMPED: Af Yes [] No G--P--,d CONCRETE PEDESTAL BY DRILLER: 0Yes � No <br /> APPROX, DEPTH 6 <br /> 2 <br /> A �^ <br /> i" <br /> PROPOSED CONSTRUCTIONIDRILLING RIETHOD: MUD ROTARY_ AIR ROTARY_ AUGER_gCABLE� OTHER_ �r�", ` I ere 550re <br /> J�pK'- .9 +� ��S Confar�Inuk�or� P��dP.rlt2c�i G��nlnS_���I'IYIS '�h2y�LlslNr �lflecl�lY�JCc3 YJ l/ .Grvjt v' , <br /> I hereby certify that I have prepared this application and that the worRIwill be in accordance with San Joaquin'County r nances, <br /> State Laws, and Rules and Regulations of the San Joaquin County. Home owner or licensed agent's signature certifies the following: 111 <br /> certify that in the performance of the work for which this permit is issued, 1 shall not employ persons subject to WORKMAN'S COMPENSATION <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, [ shall employ persons subject to WORKMAN'S COMPENSATION Laws of California." THEAPPLICANT <br /> MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 1209)468.3423. Complete drawing at lower area�provided. <br /> Signed X Title / <br /> PLOT PLAN (Draw to Scale) Scale" to­1-10A�, — <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 /> DEPART!lENT USE ONLY p C, <br /> Application Accepted By Date Area <br /> Grout Inspection By Date Pump Inspection By Date <br /> Destruction Inspection By Date Comments: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKA'ICASH RECEIVED BY DATE PERLIITISERVICE REQUEST CU12BER INVOICE <br /> 35D rq 3 ala 1)t)g <br />