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Linds4..4 <br />ApplIcetlen Accepted By <br />Acme Intpectlen By <br />Deetroctlen InepectIon By <br />Commenty <br />Date <br />DEPARTMENT USE ONLY <br />Pump Inspection By <br />Dote <br />Area <br />Date <br />APPLICATION FOR WELLIPUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION 1111_.HPli4ak -0X 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201-388 <br />(209) 460-3420 <br /> <br />SEP Pi 10: 20 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete In Triplicate) <br />APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED. T1119 APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAOUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />' <br /> <br />JOB ADDRESS/OR APPIO iJcP.T -14 (-) nicts3 Cory rbC...-KSb(\.) PARCEL SIZE/APNII I 51 -1 "; <br />Univii IL <br />I C-F KAI E <br />SUB CONTRACTOR Trcv) s, a Wool F‘At..06 <br />z <br />TYPE OF WELL/PUMP: <br />(TYPE OF FUMPI <br />0 NEW WELL <br />0 INSTALLATION <br />0 New 0 Repel, <br />0 REPLACEMENT WELL <br />0 WELL SYSTEM REPAIR <br />H.P. <br />CI MONITORING WELL I <br />ID CROSS-CONNECT REPAIR <br />DEPTH PUMP SET FT. <br />la OTHER Stit ctir <br />0 VAPOR EXTRACTION WELL <br />FIRST WATER LEVEL <br />CI OUT-OF-SERVICE <br />in DESTRUCTION: ?)) fl Reit G, <br />WELL 0 GEOPHYSICAL WELL 0 SOIL BORING <br />t- <br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br />0 0 A <br />INDUSTRIAL OPEN BOTTOM " DIA. OF WELL EXCAVATION I i IS DIA. OF CONDUCTOR CASING 0 <br />1:1 DOMESTIC/PRIVATE 0 GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA OF WELL CASING <br />0 PUBLIC/MUNICIPAL 0 DRIVEN DEPTH OF GROUT SEAL 4 '5 • SPECIFICATION <br />0 <br />MOTHER 0 IRRIGATION/AO <br />a <br />GROUT SEAL INSTALLED BY -re 9 GROUT BRAND NAME <br />............ <br />E <br />IR MONITORING GROUT SEAL PUMPED: D 0. la No <br />)......) <br />APPROX. DEPTH l.p." 1 <br />LOCKING CHESTER BOX/STOVE PIPE <br />CONCRETE PEDESTAL BY DRILLER: CI Yoe KI No S <br />S CP. <br />PROPOSED CONSTRUCTION/DRILUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1-) r-1 ,l4I.— \ <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE VVORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AN6o ., <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 WOW FOR WHICH <br />THIS rEnunT 18 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." T APPUCANT ST CALL 24 HOURS IN ADVANCE FOR AU, REGUIRED INSPECT! NS AT 12051 4I 23, COMPLETE DRAWING AT LOWER AREA PROVIDED <br />Signed X Title <br /> <br /> Date I/ <br />‘ PLOT PLAN Illrotw to Boole) Boole • to () <br />I. NAMES OF STREETS OR ROADS NEAREST TO on BOUNDING THE PROPERTY. <br />2, OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION, <br />3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED <br />ranycrunEs. INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. <br />OWNER'S NAME <br />CONTRACTOR <br />ADDRESS 4,1ec' Sh %IC, 5 r, Cxs jet c PHONE I Lie F'/C3-vp <br />ADDRESS 1(2t° ?Cl ,)/-EL LS Dr°, s rtt-iici4416-..72..3.i:-4.0N—E • 852 3 A.() <br />-70(013-‘ PHONE // si:ao <br />' <br />4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM on PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS, <br />S. LOCATION OF WEU.S WITHIN RADIUS OF ONE HUNDRED FIFTY FT <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />An.tV <br />Ice Picvli <br />p. <br />)49. YV• tn.) -- <br />EXIS i" Montior I A3 <br />Alb <br />411. <br />id • <br />et X AA <br />Pro posed <br /> r-oek.‘ po. <br />0e-ur-t- <br />Styr <br />Bids. <br />ArolJ- <br />ACCOUNTING ONLY: AIDS FACE <br />PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE 3501 V 437 1Z&4 miff q.5.fb 010320 <br />S Rpol O 32 - 0 <br />Pub. Health Serv. - Enviro. 173 (3/96)