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L <br />APPLICATION FOR WELLIPUMP PERMIT <br />1N JOAQUIN COUNTY PUBLIC HEALTH SERVI <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 9 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# 1 � I / _5' `�' 1 {— t t' �, {,•' ,? AGL CITY '.) i tt IC" l PARCEL SIZE/APNx <br />OWNER'S NAME •I}-`�'-f 1F �> I ! li C �l 1' l �; i� ADDRESS 44d U�'Ir'J' ' % � Y / [`L3 �1 f •"F Lam' P41IC -] PHONE X Z,- 7 �W4 3 <br />CONTRACTOR -I'rl� iet'�'t`` Ge`7�v' r li., 1,"�. ADDRESS('y h�_L, f+eG�', fA- �TUCX PHONE #610d iS3 160 <br />SUB <br />TYPE OF WELUPUMP: g!kEW WELL <br />.!7 <br />`, ❑ INSTALLATION <br />❑ New ❑ Repair <br />(TYPE OF PUMP) <br />11 <br />❑ REPLACEMENT WELL <br />❑ WELL SYSTEM REPAIR <br />H.P. <br />❑ OUT -OF -SERVICE WELL <br />INTENDED USE <br />TYPE OF WELL <br />❑ INDUSTRIAL <br />OPEN BOTTOM <br />,I <br />13 DOMESTIC /PRIVATE <br />��❑ <br />Ek RAVEL PACK/SIZE 7 Z <br />❑ PUBLIC/MUNICIPAL <br />❑ DRIVEN <br />❑ IRRIGATION/AG <br />❑ OTHER <br />MONITORING <br />PERMITISERVICE REQUEST NUMBER INVOICE <br />APPROX. DEPTH <br />PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY <br />ADDRESS Ajj ,-�-+`-`a— ,r-m--c=.:r—r�=� UCXE'-T-GNTT PHONE <br />MONITORING WELL #! ❑ OTHER <br />❑ CROSS -CONNECT REPAIR ❑ VAPOR EXTRACTION WELL # J <br />DEPTH PUMP SET FT. �FIRST WATER LEVELLJ O <br />❑ GEOPHYSICAL WELL # WJ SOIL BORING 7 V �' B <br />GUN5IRUGHON SPEGIFIGAIION5 A <br />DIA. OF WELL EXCAVATIIOOrN� PLC- �-� DIA. OF CONDUCTOR CASING /'Y D <br />TYPE OF CASING/STEEL) VI; � / (t� t 1 lC�t�`-� 1E'� r DIA. OF WELL CASING) 1 �'LC �� 410 <br />IC) L"'i�p'Lefe � D <br />DEPTH OF GROUT SEAL � -"(t,'i �Q :S L; '�, SPECIFICATION .SCIIti r,'P a V C_ )S <br />GROUT SEAL INSTALLED BY k yc'O7-'-1, E' pig GROUT BRAND NAME./Vie 1 V •` t, -i' O%, <br />GROUT SEAL PUMPED: ❑ Yea aN. CONCRETE PEDESTAL BY DRILLER: ❑Yea o S <br />~e '� II <br />LOCKING CHESTER BOXlSTOVE PIPE / '� t f_ 1 cL tiw`�I i- f' (� � r-' S <br />AIR ROTARY AUGER CABLE OTHER <br />I HE9EBY 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, 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, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CALIFORN , APPUCAf�F.,MLIST CALL 24 IWURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 1209) 4693423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />I/ s <br />SlpnedX � •--I``^.'`.�.�-� Title ti c'j-" :C�cIzDate t 1 S- r <br />PLOT PLAN (Draw to Seale) 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 6. 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 />Application Accepted By \L A <br />Grout Inspection By <br />Destruction Inspection <br />Com <br />DEPARTMENT USE ONLY <br />1 i Pump Inspection By <br />Date Z <br />Date <br />ACCOUNTING ONLY: AID# <br />FAC# <br />771 <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK#/CASH RECEIVED BY <br />DATE <br />PERMITISERVICE REQUEST NUMBER INVOICE <br />