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<br /> I . APPLICAIIUN FUR WELLIPUMP PERMIT
<br /> SAN JOAUUIN COUNTY PUBLIC HEALTH
<br /> SE
<br /> M,.,s
<br /> ENVIRONMENTAL HEALTH DIVISION
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<br /> i rc i P 0 BOX 398, 446'N. SAN JOAOUIN ST., STOCKTON, CA 96201.388 !
<br /> l 1209) 468.3420
<br /> I! 1 NON-REFUNDABLE PERMIT EXPIRES T YEAR FROM DATE ISSUED
<br /> I' I' (C4mPMta in Triplicate)
<br /> Appficegi,on:is hFire'byimde to th'e Son Joaquin County for a permit to construct and/or install the cork described. this applieetion fs
<br /> m�de' iM.!cvinplianclewith ,$an Joaquin County Development Title, Chapter 9.1115.3 and the Standards of San Joaquin County Public 'Health
<br /> Servibes, Enviro�mentall Health-Division.
<br /> Job Add 'sip/6 'A'N
<br /> :: :..i.,.: •, i;.
<br /> Cit
<br /> �,( , y -1:.G`" � I Parcel0O-Y214
<br /> ,S�ze APN#121 q"•/
<br /> I, Owrie�l*•-, aine'I�!1I'' li'b�tio.�'C . �,�pf►tiMY�v� �Z� �v�j�r� rtfc1:
<br /> Address_
<br /> Contractor • i�nL, 1 ` • �G Phon� # 5'f o��d 24-�Sy%(
<br /> ! Addressl�yQ DI' ,^! se L i Cf! --
<br /> .... .: Phoria #610)831
<br /> Sub.Coritrsctar• `. j �,{ i'� ' 1
<br /> .: Address O 4CA. N+vna t , l.ic#LS�6;15� °°� ZO/—eZl
<br /> 4 Fhone #.
<br /> I 1YPE`OF-WELL/PUMP!: ' IJi1V ll'WELL•' `' [) REPLACEMENT WELL Q MONITORING WELL #
<br /> [) OTHER ,
<br /> D STRUCTION []'OUT-OF-$ERVICE-WELL [] GEOPHYSICAL1
<br /> WELL #' [] SOIL BORING!*
<br /> STAL'LATION I7 IIELL SYSTEM REPAIR [] CROSS
<br /> -CORRECT REPAIR (] YAP�R, TRACTION WILL #
<br /> I' •
<br /> Repair 'H.P. DEPTR PUMP SET FT. ` r
<br /> (TYPE OF:PUMP) ;: I: _0 n --.�._... FIRST DATER LEVEL
<br /> Mw—2 a- Mw
<br /> INjENDEO I1SE .`. !? T:YP
<br /> Of WEkt. CONSTRUCTION SPECIFICATIONS
<br /> 0 INDUSTRIAL, Q,O EN BOTTOM ' DIA. OF WELL EXCAVATION
<br /> DIA.; OF. CONDUCTOR CASING
<br /> []'.DOMESTICIPRiYATE ' I71!C AVE PACK/SIZE '
<br /> 1. TYRE OF CASING/STEEL/PVC DiA.•OF WELL CASING !
<br /> °U 0UBLIG/Ml1N,ICIPAL:!:.[) {11EN: . DEPTH OF GROUT-SEAL SPFGIFICATION 1 .
<br /> 'GROUT SEAL INSTALLED BY • '
<br /> •° ! 1. CROpT'9RAH0 HARE .• ..
<br /> :; [l ►)oR•I roR IIIc .. i:.. i'
<br /> i'` GROUT SEAL PUMPED: [] Yes [)' No CONCRETE PEDESTJIL BY DRILLER: [] Yes '(]'No
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<br /> APPROJ(:IaCPTH I: :. '.I 1 LOCKING CHESTER BOX/STOVE PIPE
<br /> 1 I..
<br /> :! PROPOSEDCONS.TRUFTIONlD�IIL�INC METNOU; MUD'ROTARY�,..AIR.ROTARY_ AUCER,W„•_ CABLE,,,_••- OTHER �f'�SS✓✓�° ���.��
<br /> ' 1 herebylcerti14 ve peep@red this application and that the work will tx done in accordance with SanlJoaquin County Ordinances, '
<br /> 'State Laws and:' utas and Regulati.ons,of-the San.*Joaquin'County. Nome owner or licensed agent's'signature cert ifi.e:si the ioltowing: "I
<br /> •caclify; Lhat• ih thug performance work,fo� which this permit is •issued, 1 shall.not omptoy persons'subject to.WORKMAN'S COMPENSATION'
<br /> Laws of` Calif rnSn !' Cqn raetor�;a hir.fng or;°sub-cant rec1ing signature eertifies'the'following:'-;1 I 'certify.that! Vn.the performance
<br /> of: the.'workrf sr 'i t. (s rniit isassued, ! ' hall y persons subject to WORKMANOS COMPENSATION Laws a California:" THEAPPLICANT-'
<br /> I' . :'. 1 1 . 1. . h'.
<br /> MUST: 1124:;H U • A YA `f0 tt:il IR I PEC 10 T (2011.40-3423. Complete drawing at louec are6'providcd.
<br /> 1:
<br /> TitleDate
<br /> ! ` PLOT ;PLAN (Draw to Scale) Scale " to• f�,
<br /> ! ,1, ; Neri�es?oE.�ticetg.'oF :roeds 'nearist to or boundfny the'property. 4. Location `of house selvage disposal system of
<br /> 2. Outljne of the:proper�ti, grvinQ;dlMenslmis,end.worth direction. proposed.ekpanaion.of sewage!dTsposat`system •.,
<br /> I i3. •;Diirar5slanad-outlines:�bitf locationof all existing and proposed 5. Location.-of wells uithirr radcus:.of 150 ft. on
<br /> 1structur>:s.,,ipCtudtng cove,red•'arelis such as•patios, driveways, the property or•adjoWn:9 property.
<br /> . .. ..
<br /> :and Wel:kst i•; !., `
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<br /> i11I -
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<br /> F„'h./+wv*+e.-r�-�+.-wvvwa+� I o° r nl -!
<br /> 77
<br /> vas+rr vrv4v 3sty. E31
<br /> f ! OEPARTMENT'USE ONLY
<br /> :
<br /> App onn�ccelted'o ''. C , Area
<br /> Date"
<br /> DUE. In� ie , T
<br /> I; 1' , '• Pump Inspection By " i Date��
<br /> ;; ;:Destru4t :on`;InspectioniBy •s ' ' :Date Comments:
<br /> I, ACCOUNTINti:QNIYb ''i AIDgi FACE!
<br /> ;JlIltOUNT.R >v11TTEb'• RECEIVED-BY DATE YERMITISKRY)CE,REQUESt'NUMgLR! IMYOICE' ..
<br /> i' ._._
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