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APPLICATION FOR WELLIPUMP PERMIT �yT� I � `�, <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESlp <br />h� <aI;� I� <br />ENVIRONMFNTAL HEALTH DIVISION +� <br />P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201 ffAY 3 <br />(209) 468-3420 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSU "ECFTfni <br />(ONSTFt t@ In AND/OR <br />tal <br />INSTALL <br />pGy�fRrM l� <br />APPLICATION I6 HERE By MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUC [AND/OR IN6TAlL THE WORK DE6CRIBED.�E>f'Apj�§�I�XTbb�i/C I 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. �[ C <br />JOB ADDRESSOR AA(JPPN/ Z<05I ;7St GyIU(W J1//ZNR r— (" 47 CIT" .5 0c t TONS CA PARCEL 912E/APNI ~ 7 /?c/Z `S <br />OWNER'S NAME ICAIN&) BAK(�(U- CO. ADDRESS 32tt 6 T10–�AvE,T SACkAMR14 TU 4F 9Si;,j �gONE# 2K(o �f5/(o —.3��3 <br />CONTRACTORU�.JI fF •T LI)1 T V/C �LIING (Cll`1' ADDRESS_MFjIItA0 Q� VuVN (-A LIC<:f, 5>'F [�1ONEI &36-ZV(, <br />SUBCONTRACTOR ADDRESS UCI PHONE/ <br />TYPE OF WELLIPVMP:NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I OTHER S 5 f`426r6'-- IJ+LI.LS <br />INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS -CONNECT REPAIR ❑ VAPOR EXTRACTION WELL 0 ,y <br />(TYPE OF PUMP) ❑ New 13eP. <br />Rl, N.P. DEPTH PUMP SFT FT. FIRST WATER LEVEL 0 <br />11OUT-OF BERVIC'.F WFI.L 11 GFOIYIYRICAL WFLL I 11SOIL BORINn B <br />11 DESTRUCTION: <br />INTENDED USETYPE OF WELL CONSTRUCTION SPECIFICATIONS ,�''TT AE <br />❑INDUSTRIAL ❑OPEN BOTTOM DIA. OF WELL EXCAVATION /Vl/ DIA. OF CONDUCTOR CASING N /{ A <br />D <br />RI <br />OOMESTICA'VATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC SC H 7 2v, PLIC. DIA. OF WELL CASINO 7 1i <br />0 <br />❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL ^� /n2 F �T SPECIFICATION I/n N <br />❑IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY CCN7-AMCia/Z GROUT BRAND NAME / /r E <br />❑ MONAORINO �], GROUT SEAL PUMPED: til Yr ON. CONCRETE PEDESTAL By DRILLFR: Y. No S <br />APPROX. DEPTH 0l 'T'---P�� h 7S LOCKING CHESTER BOX/STOVE RPE ,/ 5 <br />PROPOSED CONSTRUCTION/DROWNO METHOD: MUD ROTARY AIR ROTARY AUGER X_ CABLE OTHER 1� <br />1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE HONE 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 WORK FOR WHICH <br />THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'@ COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB -CONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: • I CERTIFY THAT IN THE PERFORMANCE OF THE WOR( FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CALIFORNIA.' THE APPLICANT MUST C�SLRµ 24181 IN ADVANCE FOR AlLi�� QUREO IN PECTIONS AT 120@140@4423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />��Y,r, P V 2ENMl%N7>YL <br />/�Ul (mac( ��C�'4p � /"�LLs"�'7..1i` D.le S • 3 � • 9 S <br />X - -X -X --3E— iE----�E------3E <br />lC(:CND / <br />BURLINGTON I^P.oL,o.ed Well one PiPmy Lo,oronT <br />L f ENVIRONMENTAL <br />SM1e.I � nl 6 <br />DEPARTMENT USE ONLY (\ <br />A,,PII..IIe Aeeevlee BY 1f' <br />Grout Iroveetlon BY / F L Dele �' 1� t.` % p�mv Irwvetllon By Det. <br />0--l— <br />ACCOUNTING ONLY: <br />A— <br />FAC! <br />R CODES FEE INFO <br />I AMOUNT REMITTED <br />CHECKAIi RECEIVED BY DATE <br />PERMIT/SERVICE REQUEST Nt1MB9t INVOICE <br />3� 3 <br />c— <br />cv <br />