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APPLICATION FOR WELLIPUMP PERMIT <br /> .N JOAQUIN COUNTY PUBLIC HEALTH SERI. <br /> ENVIRONMENTAL HEALTH DIVISION <br /> PS), BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201 X88 <br /> (209) 468-3420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Camplete In Trlplicatal <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 16 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 /> /7/(,� S' /4 P-/Zo--0 <br /> JOB ADDRESS/OR APN/ �1.9�L/�iY eD, CITY PARCEL SIZE/APN/ 5- <br /> �vC�rS <br /> OWNER'S NAME 4 ,"ENTEFo) �nPHONE IADDRESS <br /> 209 <br /> CONTRACTOR Ti2C19TE,C - ADORE66,&2 V/QG 0 <br /> 67gp, l )C ,2/ LICK PHONE#—q f 3-6 S/0 <br /> SUB CONTRACTOR lyPz o,er,0710n/ /il/ ADDRESS_23C-S- yy/C GJrPM OR UC/ .S/Z 2 69 PHONE I yG S—19 712- <br /> TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I <br /> (TYPE OF PUMP) 11New 11 Repair N.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ SOIL BORING g <br /> ADESTRUCTION: / .S.�r,� S,gN,(JC/�/L��1�T G-/,,ew,/T' 7'REH/E <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION& A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D <br /> ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEELIPVC DIA.OF WELL CASING O <br /> ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH bF GROUT SEAL SPECIFICATION R <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITORING G(� GROUT SEAL PUMPED: ❑Yee [IN. CONCRETE PEDESTAL BY DRILLER:❑Yea ❑No S <br /> APPROX.DEPTH /) (/ LOCKING CHESTER BOX/STOVE PIPE S <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HE9EBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <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 WHICH <br /> THIS PERMIT IS ISSUED,1 614ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'&COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR BUB CONTRACTING SIGNATURE CERTIFIES <br /> TTI'FONG: CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT I6 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'&COMPENSATION LAWS OF <br /> C ALIFO IA.' THE PPi1CANT MUST ALL FIO IN ANCE FOR ALL REGl11RED INSPECTIONS AT 12001409-3422. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> 6lpned% T111e /�( -" DNa ✓ /�'/ 7 <br /> PLOT PLAN (Drew 10 Scale)Scat* 'to <br /> 1. NAMES OF STREETS OR ROADS NEAR (_,,6 OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF T14E PROPERTY,GIVING DISIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 2. DIMENSIONED OUTLINF8 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 /> Low/sE .�v� <br /> .. <br /> .. <br /> /20 -oy X <br /> y P , <br /> IL <br /> .;... ..:.. ...;.. ..:.. ... <br /> ..:. ..:. ... <br /> - —_ <br /> DEPARTMENT USE VI/LY <br /> Appllcetlon Accepted By 1[/�1L/V!N•�+ �"„V` Date ,/ y('-l Area <br /> Grout Inapectlon By Date Pump Inspection By Date <br /> Destrucllon Inspection BY Dale <br /> Comments. <br /> ACCOUNTING ONLY: AID# FACT <br /> PE CODE& FEE INFO AMOUNT R 17 ED CHECK//CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />