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APPLICATION FOR WELLJPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES V4(�� � <br /> ":)UMP ENVIRONMENTAL HEALTH DIVISION <br /> W y L 0 304 EAST WEBER AVENUE, STOCKTON, CA 95202 `�h <br /> (209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> (Complete M TFipRestol ffll�� <br /> APPLICATION 19 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 WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1 1 .3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLICHEAL N SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSOR APN# CITY PARCEL SIZE/APNI ♦}l <br /> OWNER'S NAM <br /> E 7 ' r ADDRESS PHONE 14l� <br /> CONTRACTOR &4tU1e 7 )a5'AI(U 50k13 LIC Q Z ] PHONE/te� <br /> �7 <br /> 16)-)6 <br /> BUB CONTRACTOR ADORESB L1C#f�6 PHONE/ <br /> Ajr <br /> TYPE OF WELL/PUMP: NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTNER <br /> ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CR088CONNECT REPAIR B VAPOR EXTRACTION WELL R J <br /> ❑New❑Repdr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> (TYPE OF PUMPI <br /> ❑ OUT-OfFSERVICE WELL ❑ GEOPHYSICAL WELL# ❑ BOIL BORING S <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPS OF WELL CONSTRUCTION SPECIFICATIONS t( A <br /> 13 INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION — DIA.OF CONDUCTOR CASINO O <br /> ❑ DOMESTICIWUVATE ❑GRAVEL PACK/SIZE TYPE OF CASINGMTEE I DIA.OF WELL CASINO D <br /> 11PUBLIC/MUNICIPAL 11DRIVEN � DEPTH OF GROUT SEAL i SPECIFICATION � 27 R <br /> 1 DATION/AO 11OTHER 7 GROUT SEAL INSTALLED BY �n�I 1 GROUT BRAND NAME E <br /> 11 11 <br /> GROUT SEAL PUMPED: ❑Yes [IN. CONCRETE PEDEBTAL SY DRILLER:❑Y« ❑Ne S <br /> APPROX.DEPTH LOCKING CHESTER SOVE PI S <br /> PROPOSED CONSTRUCTIONID ILUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> 1 HM8Y CERTIFY THAT t 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 BAN 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 08 ISSUED.I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFOFFNA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOFK FOR WHICH THIS PERMIT 19 ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' THE AgPUCANT MUST CA 24 FIDIIRe IN ADVANCE FOR ALL REQUIRED IN TIONS AT(208J_48e4428. COMPLETE DRAWING AT LOWER AREA PROVIDED. g <br /> Sturm"I X_=` J � K _Title _Q�� T note �� �� / <br /> PLOT PLAN Show to Scale)Sod. 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING 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 /> 8. 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. :... .. ... i ...: _.. .. <br /> n <br /> Y <br /> _. . . <br /> "F' _ <br /> _ .... <br /> e �.• <br /> - s <br /> .. <br /> H� ,y uivislat+ <br /> t <br /> DEPARTMENT USE ONLY <br /> Application Accepted BY b.N \41 1 Ne. a,8 <br /> Omit Inspection By not Pune Inspection 8y vete <br /> Deatnrctlen Impaction By note <br /> Conma 0: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT RWNITTED CH R)MH RECEIVED SY DAT 18 T/SERVICE REQUEST NUMBER INVOICE <br /> 3Isz, a0D 1.2 67 <br />