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APPLICATION FOR WELL PUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICLS <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388 304 EAST wEBER AVE UE, STOCKTON. CA 95201388 <br /> (209) 469.34 0 <br /> RON•REFUMpaw PERMIT EXPIRES 1 EAR FROM DATE ISSUED <br /> n TrIpI aim) <br /> APPLICATION Ili HERE BY MADE TO THE SAN JOAQUIN COUNTY FOq A PERMIT TO CONSTRUCT'ANDIG fNSTALL THE WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WRIT SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1116.3 AND THE STANDARDS OF BAN JOAOVIN OUNTY PUBLIC HEALTH SERVICES,ENVIRONMEyiAL HEALTH DIVISION. <br /> JOB ADDRESSOR APR# �� <br /> CITY t�� PARCEL*IZElAPN# <br /> OWNER'S NAME � 11 -Iy�/� 1c <br /> ✓ u �"^'��•.. .�AGGRESS l rlRca- ^I e7�� <br /> CONTRACTOR PHONE 1 <br /> ADDRESS— RICE <br /> SUB CONTRACTOR PHONE I— <br /> # <br /> — f <br /> LIC/ �PHONE <br /> TYPE OF WF,LUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING LL/ <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNEC REPAIR ❑ OTHOq <br /> ❑ VAPOR EXTRACTION WELL/ J <br /> �--, <br /> 11 Now❑Repelr N.P. DEPTH PUMP SET IFYPE OF PUMPF FT• FIRST WATER LEVEL�`T O <br /> t ❑ ow-or-SERVICE WELL ❑ GEOPHYSICAL WELLN ❑ SOIL BORING <br /> ESTRl1CTH7N: � r H <br /> INTENDED USE TYPE OF WELL CON*TRUCTION SPECIFICATION <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION A <br /> ❑ DOMESTICA'mVATE ❑GRAVEL PACKIBRE DIA.OF CONDUCTOR CASINO A <br /> TYPE OF CASINOISTEEL/PVC DIA.OF WELL CASING <br /> ❑ PUBUCIMUNIMPAL ❑DRIVEN DEPTH OF GROUT SEAL <br /> ❑ IRRIGATIONIAO ❑OTHER SPECIFICATION R <br /> GROUT SEAL INSTALLED BV GROUT BRAND NAME_ C(A�' C�Q p {� F <br /> ❑ <br /> MONITORING ' GROUT SEAL PUMPED: ❑Ys Ne <br /> APPROX.OEPFH a'�m_ � CONCRETE PEDESTAL BY DRILLER:Ely— ❑Ne g <br /> LOCKING CHESTER B X/STOVE PIPE <br /> PROPOSED CON*TRUCTIONRA ILUNO METHOD: MUD ROTARY AIR ROTARY S <br /> UGER CABLE OTHER <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUtN COUNTY ORDINANCES,STATE LAWS,AND RULES ANO ' <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFI S THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF T}TF WOOL FOR WHICH <br /> THIS PERMIT 191S8UED,1814ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS F CALIFORNIA.' CONTRACTOR'S HIRING OR gUB-CONTRACTING 81G11TURE CERTIFIER <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORI(MAN'S COMPENSATION LAWS OF <br /> CALIFO THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOURIEO INSPECTION*AT 1 1 46244". COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> BI17nad X L' Title I Q <br /> PLOT PLAN(Draw-to Seatel Soale -to <br /> 1. NAMES OF STREETS OR DS NEAREST TO OR BOUNDING THE PROPERTY. �. LOCATION OF HOUSE BEWApE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPEFIFY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION F SEWAGE WAGE I SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED `. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH As PATIOS,bFUVEWAYB,ANq WALKS. 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> ON THE PROPERTY OR ADJOINING PROPERTY. <br /> 77 : : <br /> ............ ........... <br /> .......... <br /> ............. <br /> - I { <br /> ................. ......... <br /> .................... <br /> DEPARTMENT USE ONLY <br /> fippl3catlen Aaeepted BY Derr Y' p Q �7 Aree (/• y , <br /> f <br /> Grout Irmpeallen By Date Pump Inapeetlen By Dote <br /> DertrucUen 1n.neelton By �"'"-'t Vete <br /> CemmerNe: � f/LJ'S <br /> ACCOUNTINO ONLY: ND/ FACT <br /> PE CODES FEE INFO AMOUNT AMAITTED cH CASH RECEIVED BY DAT PERMITI*13RVICE REQUEST NUMBER INVOICE <br /> �2 a`� 6e0— 0 ( 2, 61 <br /> Pub.HeaRh Serv.-Enviro.173(3196) <br />