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APPLICATION FOR WELLIPUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201.388 _ <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 JOAQUINCOUNTYPUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESSlOR AnPNN F �tlC.-�{ C!•'1 ml? JZ� D w�sT 1� ty1t/T�(JT 9>0 <br />���01-,g Vi,��,�' ICIL SSIZE/APPNN <br />OWNER'SNAME l``'''_�w)/�(�Fj ✓//��. ADDRESS (� 0 9>0x 6Z �J tI�L.�7ti_(Jn—`�—nPFiONE <br />CONTRACTOR I V Q AQC r, �LLM IJ D ADDRESS_jA,t` 27() t::;Q�=e� uA S�J �L, ('� PHONE N� <br />SUB CONTRACTOR ADDRESS S ` � ` 'J^� <br />LICN PHONE N <br />TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL N ❑ OTHER <br />t,n C ,❑ IN LLATION ❑ WELL SYSTEM REPAIR 11CROSS-CONNECTREPAIR ❑ VAPOR EXTRACTION WELL; J <br />SY �Jm E2[ 4 I�'f�—S ❑ Repelr H P DEPTH PUMP SEO_'�—FT. FIRST WATER LEVEL 4_ O <br />(TYPE OF PUMP) <br />❑ OUT -OF -SERVICE WELL ❑ GEOPHYSICAL WELL; <br />❑ DESTRUCTION <br />❑ SOIL BORING S <br />INTENDED USE <br />TYPE OF WELL <br />CONSTRUCTION SPECIFICATIONS <br />INVOICE <br />111 I/NQNSTRIAL <br />❑ OPEN BOTTOM <br />DIA. OF WELL EXCAVATION <br />A <br />DIA. OF CONDUCTOR CASING D <br />IIQ DOMESTIC/PRIVATE <br />❑ GRAVEL PACK/SIZE <br />TYPE OF CASING/STEEVPVC <br />DIA. OF WELL CASING D <br />❑ PUBLIC/MUNICIPAL <br />❑ DRIVEN <br />❑ IRRIGATION/AG <br />❑ OTHER <br />DEPTH OF GROUT SEAL <br />SPECIFICATION R <br />❑ <br />GROUT SEAL INSTALLED BY <br />GROUT BRAND NAME E <br />MONITORING <br />GROUT SEAL PUMPED: ❑ Yea ❑ No <br />CONCRETE PEDESTAL BY DRILLFR: ❑ Yee []No <br />APPROX. DEPTH <br />LOCKING CHESTER BOX/STOVE PIPE <br />S <br />8 <br />PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br />I nencoy UMI IVY IHA[ t HAVE PHt:PARFU 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: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORT( FOR WHICH <br />THIS PERMIT IS ISSUED, I SHALL 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, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CALIFORNIA.' TnNT MUST CALL 24 HOURS IN ANCE FOR ALL REQUIRED INSP NS 120e1 42. CO PLE7E DRAWING qT LOWER AREA PROVIDED. <br />Signed X Tltle .(y/ Dete��_� <br />PLOT PLAN (Drew to Scale) Scale ' 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 S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. ON THP PIWIM rry na en inrurun oo.,rxr,�-.. <br />Appllcetlon Accepted <br />Grout IMpxtlO By_ <br />D-truotlon Irapection <br />Comment.: <br />ACCOUNTING ONLY: I AID; <br />PE CODES <br />DEPARTMENT USE ONLY <br />Urt Pump iruyxtion ^y <br />FAC; <br />17995 <br />0.ti 1;j1.1_. 1( <br />FEE INFO AMOUNT REMITTED HE ;/CASH <br />RECEIVED BY DATE <br />PERMIT/SERVICE REQUEST NUMBER <br />INVOICE <br />