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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX W8, 804 EAST WEBER AVENUE, STOCKTON, CA 95201388 <br /> (109) 469.3410 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In TFipliest$) <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 MADE IN COMPLIANCE WRIT SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1 115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBL1 !{EALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESS/OR APN#�.,I �` �, ` CIT'y_ iQ- (` ;} el-N PARCEL SIZE/APN# Gt L,C` <br /> .\ —f ADDRESS � q � `1 �J[/ <br /> OWNER'S NAME { Z" PHONE R�)�"T D2 <br /> CONTRACTOR - �, �� <br /> - �- " t � � ADDRESS J �- - UC# <br /> SUB CONTRACTOR `- <br /> PHONE/, 1. <br /> TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL WSJ MONITORING WELL 4 t 3 ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR /❑`CROSS CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# -I <br /> (TYPE OF PUMP( 11New❑Repelr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING & <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ` A <br /> ❑ INDUSTRIAL �❑OPEN BOTTOM DIA.OF WELL EXCAVATION /'� \� DIA.OF CONDUCTOR CASING_ p <br /> ❑ DOMESTIC/PRIVATE .—GRAVEL PACK/SIZE ��� TYPE OF CASINO/STEEUPVC ''T DIA.OF WELL CASING ,2 O <br /> ❑ PUBLIC/MUNICIPAL DnIVEN DEPTH OF GROUT SEAL Sys ^ -i. SPECIFICATION <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY-� r'•1�� GROUT BRAND NAME '�,.. \ E <br /> MONITORING GROUT SEAL PUMPED:)(Yee ❑Ne CONCRETE PEDESTAL BY DRILLER:)Q Yee [IN. g <br /> APPROX.DEPTH_ -""i l�' LOCKING CHESTEn BOX/RTOVE PIPE <br /> S <br /> PROPOSED CONSTAUC TIO NIDRILUNO METHOD: MUD ROTARY AIR ROTARY AUGER + c CABLE OTNER <br /> I HE9EBY CERTIFY THAT 11{AVE 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:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF <br /> CALIFORNIA.' THE APPLICANT MUST CALLLLy 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTTIIIOON�SS AT 12001 4"-3422. CCO�MpP�L,EET�E,DRAWING AT LOWER AREA PROVIDED. <br /> SlOned X � / L�/JG'G 2 Tltle <br /> PLOT PLAN(Drew to Soelel Sceie�_•1e_ _' <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 /> i <br /> . <br /> d <br /> . <br /> I <br /> DEPARTMENT USE ONLY y/ <br /> APPlleetlnn Ae"epled RY beta L Aree <br /> Grout Irnnectlon By Det" Pl p Inep"etlon By <br /> Det. <br /> O-q—fl"n Imnectlon By <br /> Det. <br /> Comment.• <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CITE #ICASIT RECEIVED BY DATf PEAMITISEAVICE REQUEST NUMBER INVOICE <br /> Pub.Health Serv.-Enviro.173(3/96) <br />