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Application is here by made to the San Joaquin County for a permit to construct and/or install the work described. This appiicatian is <br /> made in compliance with San Joaquin County Development Title, Chapter 4-1115,3 he Standards of San Joaquin County Public Heatth <br /> Services, EanvironmentaL Health pDiivision<, bjlg� ?&VI 2- 1 Q: :z <br /> Job AddressJor APH#� !/1 - ��) / City /4l� Parcel Siae/APN#_ <br /> Owner's Name_ r +�''J�' l �� Address, <br /> f / � ��"` °� Phone # ami <br /> Contractor c�� tru9/� Add s l �!&J)4-e-e�Lie# �v� p Phone # <br /> 1 Sub Contractor ��d' 5 � Address ,3- �` ie2 1 Lic# _&C] 1 3_. Phone #J <br /> ' TYPE OF WELL/PUMP: NEW WELL EI REPLACEMENT WELL I1 MONITORING WELL # — (I OTHER <br /> [I DESTRUCTION [I OUT-OF-SERVICE WELL II GEOPHYSICAL WELL # 0SOIL BORING <br /> [I INSTALLATION [I WELL SYSTEM REPAIR [I CROSS-CONNECT REPAIR � U VAPOR EXTRACTION WELL_#— -J <br /> ew [] Repair M.P. DEPTH PUMP SET fr t/ FT, FIRST WATER LEVEL � � <br /> (TYPE P) <br /> I!lTENDED USEUSE TYPE OF WELL CONSTRUCTION SPECIFICATIONS If <br /> [] INDUSTRIAL L] OPEN BOTTOM DIA. OF WELL EXCAVATION_ DIA. OF CONDUCTOR CASING <br /> ' IKDOMESTIC/PRIVATE KGRAVEL PACK/SIZE- TYPE OF CASING/STEEL/PVC DIA, OF WELL CASING <br /> [] PUBLIC/MUNICIPAL C] DRIVEN DEPTH OF GROUT SEAL 2 � SPECIFDCATION <br /> E] IRRIGATION/AG [I OTHER <br /> GROUT SEAL INSTALLED BY_Jj��� GROUT BRAND NAME_ <br /> E] MONITORING �. GROUT SEAL PUMPED Tles C] No CONCRETE PEDESTAL BY DRILLER- [] Yes [I No (4 <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE, ") <br /> PROPOSED CONSTRUCTIONJORILLING METHOD- HUD ROTARY? AIR ROTARY_AUGER_ CAGLE- 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 ticer>sed agent's signature aero WORK the fCOMPENSAT "I <br /> certify that in the performance of the work for which this permit is issued, I shall not employ persons subjeet to WORKNANpS COMPENSATION <br /> Laws of California.'° Contractor's hiring or sub-contracting signature certifies the following: 11 ➢ certify that in the performance <br /> of the work for which this permit is issued, I shall employ persons subject to WoRK14ANIS COMPENSATION Laws of California.p1 THE APPLICANT <br /> MUST CALL 24 ANCE UIRED INSPECTIONS AT i209)4M.3423. Complete drawing at/lower area provided. <br /> Signed X Title '' f Date <br /> PLOT PLAN (Draw to Scale: Scale 11 to <br /> i. Hames of streets or roads nearest to or bounding the property, 4. Location of house sewage disposal system or <br /> a, 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 /> strOctures, including covered areas such as patios, driveways, the property or adjoining property, <br /> and walks, <br /> IJ <br /> J(31 Iv H -AL H S FiV_LLJ -1 1 <br /> � <br /> ' DEPARTMENT USE ONLYa� <br /> Application Accepted 8y Date <br /> Grout Inspection By <br /> d bate` �ump Inspection B <br /> i <br /> Destruction inspection BY Date_ Corcments-. <br /> ' ACCOUNTING ONLY: AID# FAC# <br /> ln� ,aafDse rFF INFO I Ai MMT REMITTED CRE` #ICASN I RECEIVED BY I DATE PER91➢TISERVICE REQUEST NUMBER INVOICE <br />