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! j AI'VLIUAIIUN IOR WELLIPUMP PERMIT
<br /> I I ! SAN JOAOUIN COUNTY PUBLIC HEALTH SERI
<br /> ENVIRONMENTAL HEALTH DIVISION
<br /> ' `+1r 0 BOX 388,446'N.SAN JOAUUIN ST„STOCKTON,CA 99201-388 1
<br /> i (209)468.3420 j
<br /> i NON•REFUN ABIE PERMIT EXPIR[B{YFAR FRDM GATE ISSUER !
<br /> (Complete to Trylicatel "T_�• i
<br /> Appl'ice'giori:is hf�re by,{40to the'�Son Josqutn County for a permit to construct arwf/or install the work described. this epplieation is
<br /> Serm3dv to, Envisnye:•wttA,Sen Jbaquin county 0evetopment Title, chapter 9.1115.5 and the Standards of San Joaquin Caunty Public health
<br /> Sery{ted, Envlrolmcnta{ iealth Division.
<br /> /'r I !
<br /> JobAddrjea'p/oF APNM +� •' CCD _ ,
<br /> (. ,,j... •. J ! , city G Parcel Sjze AP11#121 Y-/90-y�,/y3
<br /> ouncr•s•lior,, \f�=T)b ..�'�. �tl�: t'"r
<br /> rltf��.ArklreaA v r� �h7SYSt3 ph p�5"7o
<br /> Coritreccpr_•1 : /4i:FL 1- ..i/nG
<br /> I ,.. 9Y Sc— Phonet(40 8J -92.f�
<br /> + Sub Contoctoi' :+ .,Address D •}aMmana (, (. $tra 20/-02
<br /> Liel�S�(�7S$�f{phona N� i
<br /> TYDE`OFYy7ELL%PIMP:•' I#iii II'YEIL'•:'
<br /> 11 REPLACEMENT YELL [) MONITORING WELL Y .i
<br /> . i . •.17 OTHER.
<br /> I � D STRUCtIai wont-or-gRvICE WELL U GEOPHYSICAL WELL N IJ SOIL BORI,NG�
<br /> INSTACLAiION •[) iIELL SYSTEM REPAIR 1) CROSS-CONNECT REPAIR - U VAPQR,EXTRACT10 WELL R, -
<br /> !Y
<br /> N'.P. DEPTH PUMP SET T. FIRST ATER LEI(TYPE OF!" ;; l: v
<br /> ! MW-ji MW-21 Mt-1-3 a-M►v^+� I'
<br /> INTENDED:IItI .` ,. TYp 0 l CONSTRUCTION SPEL;IFICATIDIIS I
<br /> ji.'.;' li.l;
<br /> [) INDUSTRIA U1;0 EN DOTTON '
<br /> 4 DIA. OF WELL EXCAVATION
<br /> 'ji.•:'. DIA-;OF.CONDUCTOR CAST
<br /> [J'.DOMES11.CyVkIyATE:'I71!G AVEQ PACK/SIZE TYPE OF CASING/STEEL/PVC VIA.:Of YEII CAS1H4
<br /> r. +:1
<br /> "i[) PUBLIC/MUN:ICIP(1L :(lilD iVEN. . DEPTH OF GROUT-SEAL SPEC1i1CAT1ON a _—
<br /> p �RRIGATiON{AC il'O NER : GROUT SEAL INSTALLED BY
<br /> 1 I j' ; ' •j GRGUT ORA11O RAW i
<br /> . j;, : '�: I•! ••i
<br /> GROUT SEAL PUMPED: p Yes Q' No CONCRETE PEDESTAL NY DR-11
<br /> CIER: {) Yes,'[J'Na
<br /> .APPpO1f:DEP111• . j: :. '.ii:•I LOCKING CHESTER BOX/STOVE PIPE
<br /> VAOPOSEOIr.ONS.TRUFJIONjDt11lLNC METHOD: HUD ROTARY„AIR.ROTARY____AUCER_CABLE_bYHER,x �KS}✓!L�j-�j(U l�
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<br /> 1 hereby!cert)fy:I'Itbsc Illi ve Prepared the oppllcation and that the work will be done In'accorderxe�ganlJoa�Covuy Ordinances,'
<br /> ja ,'Stele Lbws and'Ryles and Rcgu)attons of-the Son Joaquin'County. Home owner or licensed egrnt's'signature certifies the ibtlowlnq: "I
<br /> car lift'Wei:rn.t)tie perior'`"nce:of:tiie'work,fo' which this permit I's Issued, T shall.hot employ persons�swiecf to.YORK)7AN'S COMPENSATION'
<br /> Laus.:It.Calif rule:!' ,Cq caetor-s hlr.ing or'sub-contrac'tang signature eertiftee'tha'followingt -r !'certify-that in.lhe performance
<br /> of the,'Yrork:( "ilii
<br /> L'..i'. . 1 :',1,s emit is:Jafl10A 1 hall y persona subfect to WORKWIS COMPENSAT:f09 Laws of.'Catfforp a:a THEAPPLICANT'
<br /> !MUST, 2Y N U Il A FO ll R IR 1 PEC 10 T(201T4/1-2427. Complete drawing at lousy. arae provided- '
<br /> ?`Si.pped',xl' TlilerS�"�Y I. : �w �c if"'Dete �ci 96
<br /> PLP.T ;PLAN (Drew to Stale) Scale'_ ) • to (� .1; '
<br /> 1, Mori as•of.gticet1. P11roeds`naares't to or bounding the'property. <. location'bf house selvage t(liksel systme or
<br /> �Z. •10utlfne�ol'tfje;propery, 'gi.viip;dlrirenslons,end.Nortlydirection. pro'posed;eitpenalon.of.sewage-dlsposal'systems. •�.
<br /> 3. ;Dti:wnslr . outlln4!111 -1acatlon of all existing end. r weed•
<br /> i 1 poi S. location of wells trlihin rad'rtls::of-.offt.'on
<br /> i gtpuctti�rs., Includ(Ag covered'areas cuch*ias•patios, driveways, y f 9 Pr P y
<br /> and Salksi Y the propert orad otnln o ert
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<br /> ' r OEPARTMENT USE ONLY ! !'`,'r•. .
<br /> ;',Appt3cot .on<Aiccelppted'U '`•` 7
<br /> i:.
<br /> crouf,iln pectrotril!y' +ii 1 i'• rte'. Date Pulp Inspection pt' j
<br /> .. .. Date
<br /> ,•:. :;DeitruEtfforti�,1)Ispeeti'Dri i Yi ;Date Comments:
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<br /> .'ACCOUNTING ONIVd;. AIDN: .. . r
<br /> I'. FACN
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<br /> PE.COpES; INFQ1';'A OUNT.RE1AtiTEb'• ;CII •%{Ck511 :RF.CEIYEO;By DATE PERMITI3ERY)CE,IIEQUESt'AUpUip!'. ;{pY010E,::,
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