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APPLICATION FOR WELLJPUMP PERMIT <br /> A SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> V 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> WA'�44 <br /> �i (209) 468-3420 <br /> V� NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in TripRcoto► <br /> APPLICATION 19 HERE BY MADE TO THE RAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1116 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALT I SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESS/OR APNI CITY PARCEL BIZE/APNI <br /> OWNER'S NAME 42SPHONE <br /> ADDRESS <br /> A <br /> CONTRACTOR ADDRESS CP d /�/I7 PHONES#4&Z-4-(o <br /> / & _ y��o <br /> PUB CONTRACTOR ADDRESS UCIPHON2 <br /> TYPE OF WELUPUMP. ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL 0 ❑ OT ER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR v VAPOR EXTRACTION WELL <br /> RYPE OF PUMP{ R J <br /> ❑New 11 Repair H.P. DEPTH PUMP GET FT. FIR WATER LEVEL O <br /> ❑ OVT-OF-BERVICE WELL ❑ GEOPHYSICAL WELL I ❑ SOIL BORING S <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ,�pA� A <br /> ❑ INDUSTRIAL 11 OPEN BOTTOM DIA.OF WELL EXCAVATION U DIA.OF CONDUCTOR CASINO D <br /> ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE, TYPE OF CASINO/STEE116 <br /> �+ DIA.OF WELL CASINO D <br /> ❑ PUBLIC/MUNICIPAL 1:1DRIVEN ,�Q _{' ) bEPTH OF GROUT SEAL - n SPECIFICATION R <br /> ❑ IRRIGATION/AO ❑OTHER G" GROUT SEAL INSTALLED BY \' � * OROVT BRANDNA� E <br /> ❑ MONITORING ' GROUT SEAL PUMPED: ❑Yea ❑Ne CONCRETE PEDESTAL BY DRILLER: Yea ❑Ne S <br /> _ <br /> APPROX.DEPTH ��� LOCKING CHESTER BOX/ST <br /> S <br /> PROPOSED CON8TRUCTIONIORILLING METHOD: MUD ROTARY AIR ROTARY AUGER__CABLE OTHER <br /> 1 HEREBY 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 /> T1419 PERMIT IB ISSUED,I$HALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF <br /> CALIFORNIA.' T A P NT MUgT CALL URS IN ADVANCE FOR ALL REQUIRED INSPECTION$AT 1200144k-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Stoned X I•:e � Title Date <br /> PLOT PLAN(Draw to Boole►goale to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE BEWAOE DISPOSAL SYBTEM On PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSION$AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALK$. ON THE PROPERTY OR ADJOINING PROPERTY, <br /> .... <br /> .. .. .. .. ....:. ..,.. .... <br /> v['r <br /> G U <br /> - �9 <br /> J� JUA lONCOO 1(l <br /> PU13LI <br /> G HEALTH SERVICES _. <br /> ;. pVIROREPSAL HEATH DIVISION. . <br /> �- <br /> L ...... ............. .. . .......... ............................................... <br /> Uk r <br /> DEPARTMENT USE ONLY <br /> APpllostlon Accepted By Date ` Area f�� <br /> Orom Inspection BY not. ( 1 Pump Inspection BY Date <br /> Dostroetlon Impoetton SY Date <br /> C.mments: <br /> ACCOUNTING ONLY: AID# FACT <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKNICASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> t5 ' 3 <br /> Pub.Health Serv.-Enviro.173(1/97) <br />