Laserfiche WebLink
' icomplele 0 inplleetal <br /> Application is here by made to the San Joaquin County for a permit to construct and/or instal[ the work described, This application is <br /> made In d.ompliance with San Joaquin County Development Title, Chapter 1115.3 And the Standards of San Joaquin County Public Health <br /> Services, EnvironmentalHeal_t_h pDiv3sions.�ldn f ' �p����yy�- <br /> ' Job Address/lir APN* 6,//5 ~1 K a�✓city �f /d�/Q Parcel Size/APNIR <br /> _ <br /> Owner's Name j�T/b C 0__ Address <br /> / ��"�/51,F1R7 Phone <br /> Contractor LJ f// �i' Add eSs�2 tri /f�.. Z� -�63 ic* Phone aY���r�� <br /> ' Sub Contractor �d� � 5 l�✓ ��� Address ✓_�7 2T ICZ¢ � - Lic* Phone #�Lf.S-I✓73� <br /> ' TYPE OF WELL/PUMP-. IX NEW WELL [I REPLACEMENT WELL [I MONITORING WELL OTHER <br /> [I DESTRUCTION [I OUT-OF-SERVICE WELL [I GEOPHYSICAL WELL * [j SOIL BORING <br /> y CI INSTALLATION [1 WELL SYSTEM REPAIR CJ CROSS-CONNECT REPAIR [I VAPOR EXTRACTION WELL. #— <br /> ��r� Jew !I Repair H,P� DEPTH PUMP SET FT. FIRST WATER LEVEL L�?I B <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> 11 INDUSTRIAL [J OPEN BOTTOM DIA. OF WELL EXCAVATION Id- DCA. OF CONDUCTOR CASING 'may <br /> ' DOMESTIC/PRIVATE GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC , DIA. OF WELL CASING �ip <br /> 11 PUBLIC/MUNICIPAL Ll DRIVEN DEPTH OF GROUT SEAL � � SPECIFICATION r� �/9n <br /> 11 IRRIGATION/AG C) OTHER GROUT SEAL INSTALLED BYr����L'J� - GROUT BRAND WANE r��✓a✓ � i <br /> ' [I MONITORING r GROUT SEAL PUMPED les 11 No CONCRETE PEDESTAL BY DRILLER, 0 'Yes [I No <br /> APPROX.DEPTH_ ) LOCKING CHESTER Box/STOVE PiPE_ <br /> PROPOSED CONSTRUCTIONIDRILLING METHOD- MUD ROTAR; AIR ROTARY® AUGER® CABLE OTHER® <br /> I hereby certify than: 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.- 01i <br /> certify that in the performance of She work for which this permit is issued, I shall not employ persons subject to,"KIAIIS COMPENSATION <br /> ' Laws of California." ContractorEs hiring or sub-contrasting signature certifies the follawing. 11 I certify that in the performance <br /> of the work for which this permit is igsued, I shall employ persons subject to WORKMAN'S COMPENSATION Laws of California." THE APPLICANT <br /> MUST CALL 24 A ANCE �JREONSPECTIO�AT9)49it•3423. Complete drawing at lower area provided, <br /> Signed M � -- T6tL j � Date <br /> ' PLOT PLAN (Draw to scale) Scale- <br /> 10 <br /> cale " to <br /> 10 News 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, an <br /> s-rOctures, including covered .areas such as patios, driveways, the property or adjoining property. <br /> and walks. <br /> I - <br /> S - <br /> DEPARTMENT USE ONLY A � <br /> Application Accepted By t Date d Areae.?r� <br /> 1-01 <br /> Grout Inspection B tffDatet Pump Inspection B)/ Date i <br /> Destruction Inspection By Date _ Comnenta- <br /> ACCOUNTING ONLY. AID# FAC* <br /> PE CODES FEE INFO AM T REMITTED I 01FEalICASHiRECEIVED BY =DATE PERMITI3E NICE REQUEST NWitBER INVOICE <br />