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APPLICATION FOR WELLIPUMP PERMIT (.*N. <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOAQUIN Sr, STOCKTON, CA 95201-388 <br /> (209) 488.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 TEAR FRONT DATElSSUED <br /> i <br /> APPLICATION IS HERE SY MADE TO THE SAN JOAQUIN COU (CBmpble M TTgIleale) <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS pp SCONSTpUCT AND/on INSTALL THE�OU N COUNTY PUBLIC HEALT RK DESCRIBED.THIS <br /> EINVIRONMENTAL HEALTH DIVISION. WITH SAN <br /> JOB ADDRESSOR APNN 1��1—1�rs1 C,p_\ ^n J ' i <br /> OWNER'S NAM �jjn ['�,tr j►'� r. PARCEL APN,t <br /> ADDRESS <br /> /i, r <br /> CONTRACTOR PHO <br /> U ••/LR�y Lyl C# V 90 712 <br /> sue CONTRACTOR lw L(�t1 j� // 7�1 4J 'PHO <br /> „ADDRESS 0�� rte �Ji{/ Ai9 PHONE•E�vY I' <br /> TYPE OF�MP• ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING <br /> WELL# .�yI —~~ <br /> ❑ INSTALLATION ❑WELL SYSTEM REPAIR /LST OTHER <br /> ❑CROSS-CONNECT REPAIR 13 VAPOR EXTRACTION WELL X ��" <br /> 0 New❑Repafr H.P. DEPTH PUMP SET J . <br /> (TYPE OF PUMPY FT FIRST WATER LEVEL O ` <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL#' ❑ SOIL BORING�" 9 <br /> ❑DESTRUCTION: � <br /> N7ENDm USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS F <br /> ❑INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION •/Z,r A <br /> ❑OOMESTICMNVATE ❑GRAVEL PACKISIZE DIA.OF CONDUCTOR CASING D <br /> TYPE OF CASINGlSTEELlPVC DIA,OF WELL CASING <br /> ❑ PUBLIClMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL l D <br /> ATIONlAG SPECIFICATION R <br /> ❑OTHER GROUT SEAL INSTALLED BY <br /> GROUT BRAND NAME E <br /> ONtTOPTH GROUT SEAL PUMPED; ❑Yes a CONCRETE PEDESTAL BY DRILLER;❑Yes [IN. S IF <br /> APPROX.DEPTH LOCKING CHESTER BOXlSTOVE PIPE <br /> PROPOSED CONSTRUCTNTNmRlLIINO' METHOD: MUD ROTARY S <br /> AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN 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,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: "t CERTIFY THAT IN THE PERFORMA CE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WOItK1MAN•i COMPENSATION LAWS OF <br /> CALIFORNIA." CALL Z4 HOURS NCE FOR ALL REQUIRED SPECTIONS AT(200)4"e3423 COMPLETE DRAWING AT LOWER AREA VIDED.�j <br /> 8laned X Title <br /> Date f <br /> (Draw to <br /> 1, NAMES OF STREETS OR ROADS NEAREST TO OR ND NG Tto <br /> H NPROPERTYeT�� "to <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> ON THE PROPERTY OR ADJOINING PROPERTY. <br /> . <br /> ....:... - ....p. - - <br /> .... - ' <br /> ---- : - 5.... ..,......- : , <br /> .2 . 19 5 <br /> .. <br /> ... <br /> E�' VIRONMENfAi 4A [4';'L <br /> _. <br /> PERMIT/SERVICES .. <br /> DEPARTMENT USE ONLY - <br /> Application Accepted by •t. _ -"_..�.:..: :�--..max, --=- - ^^-..- - -�.rirr`� <br /> �� •" :�..'�- - <br /> Grout Inspection ey aG <br /> bete Pump Inspection By Onto <br /> Destruction Inepectl n a <br /> Date <br /> Comm4nts- - -- <br /> ACCOUNTING ONLY; AID# FACR <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKIICASH RECEIVED BY DATE P"WITISERVICE REQUEST NUMBER INVOICE <br /> 61 <br /> SD �` /n a� <br />