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APPLICATION FOR VVELLIPUMP PERMIT _--- ---- -- - ----- <br /> • SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES . <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388,448 N.SAN JOAOUIN ST., STOCKTON,CA 95201388 <br /> (209)468-3420 <br /> NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> iCempWle M Tripgoml <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 Sen Joaquin County Development Title, Chapter 9-1115.3 and the Standards of Sen Joaquin County Public Health <br /> Services, Enviromwnt/al,"Health Division. - 1 �.r�� <br /> Job Address/or APNN_ -,, N. llo"W k-A) /l City- /-M J Pereal Slxe/APNR I/tx� <br /> Owner's Havee e'hft: C; -1/f'N6r7 �1 Address /"e,' Bclx S,//y ,SJW 64 Phone / <br /> Contractor/1L'FAf�/V^y(,�ezz/1j:: 'JJ&-�/Jir%YNGs.4`( Address&t3 0- A&� zIl 401) 7$`151 Lic;F phone #-2P,02&1/ <br /> te�{{ '02 <br /> SW Contrsctor7ei7 Address-W(S/yt p4 Bothe ic\452�:76?6 Phone 44,0-7- <br /> TYPE <br /> lD '�yil'Z rry <br /> TYPE OF HELL/PU1P: )OEW WELL (] REPLACEMENT WELL Ff.MONITORING WELL Al L 1) �•-'�7 OTHER <br /> [1 DESTRUCTION U WT-OF-SERVICE WELL (] GEOPHYSICAL WELL Al IT SOIL BORING <br /> D INSTALLATION D WELL SYSTEM REPAIR D CROSSCONNECT REPAIR D VAPOR EXTRACTION WELL a_ <br /> (TYPE OF PUMP) (] New 0 Repair X.P. DEPTH PUMP SET_FT. FIRST WATER LEVEL <br /> INTENDED USE TYPE OF Wit CONSTRUCTION SPECIFICATIONY <br /> [] INDUSTRIAL [I OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING <br /> 'AJ/4 <br /> 0 DONESTIC/PRIVATE U GRAVEL PACK/SIZE_ TYPE Of CASING/STEEL/PVL DIA. OF WELL CASINGr <br /> 0 PUBLIC/MUNICIPAL D DRIVEN DEPTH OF GROUT SEAL CTS / SPECIFICATION a <br /> (1 IRRIGATION/AG [I OTHER GROUT SEAL INSTALLED BY'uBG Lt7✓�A'T GROUT BRAND NAME /Zlc/GhNu) <br /> [] MONITORING GRWT SEAL PUMPED: IT Yes'-;,PT No CONCRETE PEDESTAL BY DRILLER: (] Yee (] No <br /> APPROIL DEPTH LOCKING CHESTER BOK/STOVE PIPE rxor,-c go^ r7-t'-S 4� <br /> PROPOSED COMSTRUCTIONIORILLIND METHOD: MAI ROTARY_AIR ROTARY_ AUGER GABLE_OTHER_ <br /> 1 hereby certify that 1 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. R. owner or licensed agent's signature certifies the following: "1 <br /> certify that in the performance of the work for which this perott to issued, 1 shell not employ persons subject to WORKMAN'S CONPENSAT ION <br /> Laws of California.-- Contractor's hiring or sub-contracting signature certifies the following: " 1 certify that in the performance <br /> of the work for wehjcjithis permit is issued, 1 shallfnploy persons subject to IIORKMAN'S COMPENSATION Laws of California." THE APPLICANT <br /> MUST CUL 24 pB -- NN CD/V RE FOR AL FOUhRE�O I�NSpf�L610N6 A7 IE0114W-7153. Carplete drawing et lower area/provided. <br /> Signed% ✓ Title ��✓E2%L�tGG/S% Dete_ <br /> PL PLAN (Drew to Scale) Scale_• to <br /> 1. Names of streets or roads nearest to or bounding the property. 6. Location of house sewage disposal system or <br /> 2. Outline of the property, giving ofinensi ors; and North direction. proposed expansion of sewage disposal systems. <br /> 3. Diewrsioned outlines and location of all existing end 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 .elks. <br /> OEPARTNENT USE ONLY <br /> Application Accepted By Detet `T Area <br /> Grout Inspection By Date Pump Inspection By Date <br /> Destruction Inspection By Date Comments: <br /> ACCOUNTING ONLY: AION TACO <br /> PE CODES FEE INFO AMOUNT REMITTED I CH CASH RECEIVED BY DATE PERMITjSERVICE REQUEST NUMBER INVOICE <br />