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APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON, CA 95202 WELL <br /> (209)468-3420 / , - <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> IComplets in TripRedo) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WrTH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 ANO THE 8TANOARDS OF SAN JOAQUIN COUNTY <br /> YPPUBBUC/HEALTH OFFIVICER.ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADbRESS/OR APN# 5 ;�n 2L-- CITY <br /> _PARCEL SIZE/APN/ <br /> OWNER'S NAME 6 ADDRESS'fZ V!autl PHONEI <br /> �_ACONTRACTOR <br /> y LIC/ PHONE# ��� <br /> OUR CONTRACTOR 'W G�L�U AOOI � Y( LICI!%� PNDNfi/ <br /> TYPE OF WELUPUMP: RfNIW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER <br /> -❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR VAPOR EXTRACTION WELL I J <br /> ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> (TYPE OF PUMP) <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ SOIL SORNG B <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �rl� A <br /> 11 INDUSTRIAL 11 OPEN BOTTOM 9 DIA.OF WELL EXCAVATION L DIA.OF CONDUCTOR CASINO O <br /> ❑ OOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEF. V j DIA.OF WELL CASINO D <br /> 11MIRUC/MUNICIPAL 11ONVEN 1J✓` DEPTH Of GROUT REAL SPECIFICATION ]� R <br /> ❑ IRRIGATION/AG ❑OTHER eGROAT SEAL INSTALLED BY L/,r7 II N ti-'L._ GROUT BRAND NAME -- 1> E <br /> ❑ MONITORING 7-0 GROUT SEAL PUMPED: ❑Yes [IN. CONCRETE PEDESTAL BY DRILLER:❑Yes [IN. S <br /> APPROX.DEPTH LOCKING CHESTER BOXI� S <br /> PROPOSED CONSTRUCTION/DRLUNO METHOD: MUD ROTARY AIR ROTARY AUGER 'V CABLE OTHER <br /> 1"MRY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT T14E WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AOENT'8 SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,1 814ALL 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 @HALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' THE APPUqmT M T 4 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12091488-3422. COMPLETE DRAWINO AT LOWER AREA PROV10 <br /> Signed X�{� Title f/�L �J � Dete 12/ h y <br /> PLOT PLAN(Drew to Social Seals 'to <br /> 1. NAMES OF STREET8 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 RAOIU@ OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> .... <br /> 0 <br /> .. <br /> a <br /> . <br /> . . .. . <br /> .. . <br /> . <br /> DE�. " ; <br /> . <br /> Sr,N JUAQ illry ._. <br /> u H svlcs <br /> FfJ'UI51L)iv <br /> PUBLIC HEA <br /> .._._ : .... .. nDNIRONMENTA1.fiErAl.r..l <br /> t <br /> DEPARTMENT U@E ONLY <br /> Application Accepted By N.Tm Date Ares �r <br /> O-ut Inspection By Date Z Pump Inspection By Date <br /> Doslruetlan Impaction By Date <br /> Commonle: <br /> ACCOUNTING ONLY: AIDI FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK//CAS" RECIVED BY DATE PERMITISEAVICE REQUEST NUMBER INVOICE <br /> Dz/ 3 <br /> Pub.Health Serv.-Enviro.173(1/97) <br />