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APPLICATION FOR INELLIPUMP PERMIT <br /> SAN JOAOUIr'—'1 PUBLIC HEALTH SERVICES <br /> ENV19.. ENTAL HEALTH DIVISION <br /> P 0 BOX 388,446 N.SAKI JOAQUIN ST,STOCKTON,CA 96201.388 <br /> (2091468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> iCOMPlau Ia Trglkaui <br /> Application is here by made to the San Joaquin County for a permit to construct arid/or install the work described. This application is <br /> made in compliance with San Joaquin County Development Title, Chapter 4-1115.3 and the Standards of San Joaquin County Public Health <br /> Services, Environmental Health Division. lfn� l <br /> Job Addressor APN# 27 0 S 7 S1 +V 1 [ ��.L City Pa tel size <br /> Address ' Phone# <br /> 5 <br /> owner's Heme 1 71 <br /> Address ! ic# Phone #� <br /> Contrector <br /> Sub contractor ! 1 1 1 _Address Lic# Phone # <br /> TYPE OF WELL PUMP- [7 NEW WELL [7 REPLACEMENT WELL E] MONITORING WELL # [] OTHER <br /> - ❑ DESTRUCTION [] OUT-OF-SERVICE WELL [] GEOPHYSICAL WELL # [] SOIL BORING <br /> [) INSTALLATION [7 WELLS STEM REPAIR [] CROSS-CONNECT REP [7 VAPOR EXTRACTION YELL # <br /> S <br /> ­xNew [] Repair H.P. DEPTH PUMP SET FT• FIRST HATER LEVEL/ <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELI, CONSTRUCTION SPECIFICATIONS <br /> [7 INDUSTRIAL [] OPEN BOTTOM DCA. OF WELL EXCAVATION DIA, OF CONDUCTOR CASING <br /> M DOMESTIC/PRIVATE [] GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA. OF WELL CASING <br /> [] PUBLIC/MUNICIPAL [] DRIVEN <br /> DEPTH OF GROUT SEAL SPECIFICATION <br /> IRRIGATION/AG C] OTHER <br /> GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> [] MONITORING GROUT SEAL PUMPED: [] Yes [7 No CONCRETE PEDESTAL BY DRILLER: [] Yes [] No <br /> APPROX.OEPTN LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTRUCTION+DRILLING METHOD: MUD ROTARY_AIR ROTARY_AUGER_ CABLE_OTHER <br /> 1 hereby certify that I have prepared this application and that the xork will be done in accordance with San Joaquin County Ordinances, <br /> ollowing: -1 <br /> State Laws, and Rules and Regulations of the San Joaquin County. Home owner or licensed agent' sons subject tosignature �fthe fies WORKMAN'SCOMPENSATION <br /> certify that in the performance of the work for which this permit is issued, I shall not employ perthat in <br /> Laws of California."cContractor's hiring or sub-contracting perso personssubjecttoture ifies the WDRK14ANISfCOMPENSATION Laws oflCalifornia."h THE APPLICANT <br /> of the work for which this permit is issued, i shell employ pe � i <br /> UI�IMSPEVC;TIDKSATI ORIMUST CAII 24 HNDAR 3423. Complete drawing at L er area provided. ��{{ 6 <br /> Titl Dat�+ <br /> *— <br /> Signed X <br /> PLOT PLAN (Draw to Scale) ScaLe1 " tO <br /> 4. Location of house sewage disposal system or <br /> 1. Names of streets or roads nearest to or bounding the property. ro sed expansion of sewage dispose[ systems. <br /> 2. Outline of the property, giving dimensions and North direction. P Pv 1� <br /> 5. Location of wells within radius of 150 ft. on <br /> 3. Dimensioned outlines and location of all existing and proposed or the propertyad oining property. <br /> structures, including covered areas such as patios, driveways, J <br /> and walks. <br /> DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted By -- <br /> Date Pump Inspection By r� a2e1L--,3 <br /> Grout Inspection By RECEIVED <br /> Destruction Inspection By <br /> DDate Coents: <br /> - mmAUG 3 1 1994 <br /> FAc# SAN JOAQWN COizvICES <br /> UNTY <br /> FMASK <br /> eeII ��TT❑ .yz <br /> ASH RECEIVEO BY DATE PERMRISEAVICEE�PNBER" iNY�ICF]li!{SIO <br /> V <br />