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APPLICATION FOR WELLIPUMP PERMIT <br />JAN JOAQUIN COUNTY PUBLIC HEALTH SERVILcS <br />ENVIRONMENTAL HEALTH DIVISION <br />P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201.388 <br />(209) 468-3420 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete in Triplicate) <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 WITH SAN <br />JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1115,3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR APN# NORTHWEST CORNER OF FRENCH CAMP RD S,TTWY-99, FRENCH CAMP <br />PARCEL SIZE/APN# <br />OWNER'S NAME CANADA COVE ADDRESS P .0 . BOX 66, HALF MOON BAY, CAJ4P19 983-8384 <br />CONTRACTOR NOACK PUMP COMPANY ADDRESS 4500 E. FREMONT ST LIC# 504513 PHONE# 948-8817 <br />SIOCKION, CA 95 <br />SUB CONTRACTOR <br />ADDRESS LIC# PHONE # <br />TYPE OF WELUPUMP: yy❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL # ❑ OTHER <br />Ap. INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS -CONNECT REPAIR ❑ VAPOR EXTRACTION WELL # J <br />TURBINE Ad New ❑ Repair H.P. 15 HP DEPTH PUMP SET 85 FT. FIRST WATER LEVEL 47 O <br />(TYPE OF PUMP) <br />❑ OUT -OF -SERVICE WELL ❑ GEOPHYSICAL WELL # ❑ SOIL BORING R <br />❑ DESTRUCTION <br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br />❑ INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING D <br />DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYf&er6/ "TNG/,IilTkEUPVC DIA. OF WELL CASING D <br />❑ PUBLIC/MUNICIPAL ❑ DRIVENr <br />DEkk.OF,GROUTfSEAL SPECIFICATION q <br />❑ IRRIGATION/AG ❑ OTHER— GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br />El MONITORING - GROUT SEAL PUMPED: ❑ Yes [IN. CONCRETE PEDESTAL BY DRILLER: ❑ Yea ❑ No S <br />APPROX. DEPTH LOCKING CHESTER BOX/STOVE PIPE S Q <br />PROPOSED CONSTRUCTION/DRILLINO 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 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 FOLLOWINU —^y RTIFY THAT IN THE PERFORMANC THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'$ COMPENSATION LAWS OF <br />CALIFORNIA.' THE APPU ANT MUS ALLi7 IWtiAS I MANCE FOR ALL REQUIRED INSPECTION$ AT (209) 4683423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />1 'r C/GC e1r <br />Slaned X Title_ RFTATI SA FS Date 2-13—A5 <br />�J <br />PLOT PLAN (Draw to Scale) Seale ' to <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 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. nu Tuc oanocvry ..o ... <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />Comments: <br />DEPARTMENT USE ONLY <br />Date Pump Inspection By <br />Area <br />Date <br />ACCOUNTING ONLY: <br />AID# <br />FAC# <br />PE CODES <br />r <br />FEE INFO <br />AMOUNT REMITTED <br />I <br />CHEC /CASH <br />RECEIVED BY <br />DATE PERMIT/SERVICE REQUEST NUMBER <br />INVOICE <br />Lh <br />