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APPLICATION FOR VVELUPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388,445 N.SAN JOAQUIN ST,STOCKTON.CA 9520138/ <br /> (2091 4883420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Camplab M Tijlieata) <br /> Application is here by Rade to the San Joaquin County for a permit to construct and/or install the work described. This appiication is <br /> made in cmpLiance with San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br /> Services, Environ entaL Health Division. !!�� <br /> Job Address/or APN# T77 (C 910 Ls" k,7 City If',7c Parcel S17e/APMN_ <br /> ` �7 Phone # �26^3 <br /> Owner's Name ��,�• C r'•�� Y(`�,r�_c�t �� Address G- � y�S <br /> Contractor �J� .;, A j�,r-S.r i'c'r c p Address/ %L�'. t��'l'4[i.iJh'r_ Lich C.��L3 S Phone N ,IF 'Y//L <br /> Sub Contractor Address Lich Phone N <br /> TYPE OF WSLLIPUMP. I] NEW WELL CI REPLACEMENT WELL ❑ MONITORING WELL # [I OTHER <br /> (I DESTRUCTION [I OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL N [I SOIL BORING <br /> ! [I INSTALLATION C] WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR I': VAPOR EXTRACTION WELL N <br /> -S c<}� [I Mew R'Repair 14.P. ��_ DEPTH PUMP SET_ J!�t2 _FT. FIRST WATER LEVEL- d' <br /> (TYPE OF P(.MP] <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> [I INDUSTRIAL ❑ OPEN BOTTOM DIA. Of WELL EXCAVATION DIA. OF CONDUCTOR CASING —p <br /> a <br /> [I DOMESTIC/PRIVATE CI GRAVEL PACK/SIZE­ TYPE OF CASING/STEEL/PVC DIA. OF WELL CASING <br /> ❑ PUBLIC/MUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL _ SPECIFICATION <br /> (] IRRIGATION/AG [] OTHER GROUT SEAL INSTALLED BY _ GROUT BRAND'NAME <br /> (] MONITORING GROUT SEAL PUMPED: [I Yes [I No CONCRETE PEDESTAL BY DRILLER: CI Yes (] No 1 <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE_ Jz <br /> PROPOSED CONSTRUCTIONIDRILLINB METHOD: MLA ROTARY__ AIR ROTARY_AUGER_CArLE OTHER_ <br /> 'o <br /> 1 hereby certify that 1 have prepared this apptication and that the work will be done in accordance with San Joaquin County Ordinances, <br /> . <br /> State Laws, and Rules and Regulations of the San Joaquin County. Home owner or Licensed agent's signature certifies the following: "I 71z) <br /> certify that in the performance of the work for which this permit is issued, [ shall not empkoy persons subject to WORKMAN'S COMPENSATION C-1- <br /> Laws <br /> yLaws of California." Contractor's hiring or sub-contracting signature certifies the following: 11I certify that in the performance <br /> of the work for which this permit is issued, I shall employ persons subject to WORKMAN'S COMPENSATION Laws of California." THE APPLICANT <br /> MUST CALL 24 HOURS I ADVANCE FON ALL REQUIRED INSPECTIONS AT 020114883423. Complete drawing at lower area provided. <br /> Signed X 1i.d[- �'i.'I� r I Title Ly/' j✓ !/-- Date/C' <br /> PLT PLAN (Draw to Scale, Scale " to <br /> 1. Names of streets or roads nearest to or bounding the property. G. 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. on <br /> structures, including covered areas such as patios, driveways, the property or adjoining property. <br /> and walks. <br /> �.r <br /> 5 <br /> 4 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By I DaDaatt/e��,T Area <br /> Grout Inspection By Date Pump Inspection B�/tom-- � a�-<.r Dat-4Y�,`� <br /> Destruction Inspection By Date Coments: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE !DOES FEE INFD AMOUNT REMITTED li1JTCASH RECEIVED BY DATE PENM[TISERYICE REQUEST NUMBER INVOKE <br /> L; 9 O [ <br /> i <br /> I __ <br />