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APPLICATION FOR WELLIPUMP PERMIT <br /> 1-0 SAN JOAQUIN COUNTY PUBLIC HEALTH SERl�,3 <br /> ENVIRONMENTAL HEALTH DIVISION PAYMENT <br /> P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 95201.388 RECEIVED <br /> (209) 468-3420 <br /> .JUN 2 4 19.906 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) SAN JL) IN QQt1NTY <br /> Application is here by made to the San Joaquin County for a permit to construct and/or install the worrj "Pt1b�itE s <br /> made in compliance with San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of an o y Nyii tQ N <br /> Services, Environmental Health Division. <br /> Job <br /> Job Address/or APN# 0� YV �iyC/aC. �t City Ee die,•/ Parcel Size/APN# L <br /> Owner's Name {�lJ�(� � /lnn.W�PCiI�/�^ Address I ! ��� Iti'tTC Phone # O <br /> Contractor�✓)9v3' l� ��vVl�(_Q• Address 'W43 NArrir'C� LA Lic# Phone #9 <br /> S 1 t�Lplt�,fg �w�•1 4�P�1 Addr ss�3 �Y � � � Lic# 58a691� Phone e #9s -73-2 <br /> Sub Contractor o� <br /> v <br /> TYPE OF WELL/PUMP: NEW WELL [I REPLACEMENT WELL W MONITORING WELL # [I OTHER <br /> [I DESTRUCTION [I OUT-OF-SERVICE WELL [I GEOPHYSICAL WELL # [I SOIL BORING <br /> [I INSTALLATION (I WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR [I VAPOR EXTRACTION WELL # <br /> [I New [I Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL r <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> [I INDUSTRIAL [I OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING <br /> [I DOMESTIC/PRIVATE Q-tRAVEL PACK/ I 0--0� TYPE OF CASING/STEEL/PVC ani DIA. OF WELL CASING <br /> [I PUBLIC/MUNICIPAL [I DRIVEN DEPTH OF GROUT SEAL -T-I> Serf{+-2_ SPECIFICATION <br /> [IIIRRIGATION/AG [I OTHER GROUT SEAL INSTALLED BY �S GROUT BRAND NAME <br /> J.�MONITORING GROUT SEAL PUMPED: [I Yes [J�,No CONCRETE PEDESTAL BY DRILLER: [I Yes [moo <br /> APPROX. DEPTH LOCKING C STER BOX/STOVE PIPE <br /> PROPOSED CONSTRUCTIONJDRILLING METHOD: MUD ROTARY_ AIR ROTARY_ UGE ABLE_ OTHER_ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, <br /> State Laws, and Rules and Regulations of the San Joaquin County. Home owner or licensed agent's signature certifies the following: "I <br /> certify that in the performance of the work for which this permit is issued, I shall not employ persons subject to WORKMAN'S COMPENSATION <br /> Laws of California." Contractor's hiring or sub-contracting signature certifies the following: " 1 certify that in the performance <br /> of the work for which this permit is issued, 1 shall employ persons subject to WORKMAN'S COMPENSATION Laws of California." THE APPLICANT <br /> MUST CALL/244 HOURS <br /> IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT (201)4883423. Complete drawing at lower area provided. / /zy& <br /> Signed X ✓`�V�1'��.' ti 0 _ Title Ge+ L�S� Dates <br /> PLOT PLAN (Draw 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 <br /> 2. Outline of the property, giving dimensions and North direction. proposed expansion of sewage disposal systems. <br /> 3. Dimensioned outlines and location of all existing and proposed 5. Location of wells within radius of 150 ft. on <br /> structures, including covered areas such as patios, driveways, the property or adjoining property. <br /> and walks. <br /> I L ­PnW <br /> DEPARTMENT USE ONLY <br /> Date V V4 '0 1_ Area <br /> Application Accepted By <br /> Grout Inspection By <br /> Date Pump Inspection By Date <br /> Destruction Inspection By Date Comments: <br /> [ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> b i i �l <br />