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APPLICATION FOR WELLIPLIMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SER.— p <br /> ENVIRONMENTAL HEALTH 01VISION 9 241 <br /> zv <br /> P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CO26 <br /> (209) <br /> - <br /> {209) 488.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED O M Y 2 1385 <br /> (Complete le Tripliaoto) r <br /> Application is here by made to the San Joaquin County for a permit to construct and/or install the work E&TALB ion is <br /> made in compliance with San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of JOB �s�LR�S�tnHealth <br /> Services, EnvironmentalgHealth Division. <br /> Job Address/or APN# �-I c� ►v Y ��y�n �ciity �n n / r_ Parcel Size/APN# Al �7 <br /> Owner's Name Address- L—I 5 V Y v��C YA L9 VTA)U Phone #`t <br /> Contracto�jh\V"rw, ) r Address Lic#dl6-T{O Phone i! l� <br /> Sub Contractor Address ~' Lic# Phone # <br /> TYPE OF WELL/PUMP: [I NEW WELL [I REPLACEMENT WELL 0 MONITORING WELL # [I OTHER <br /> [I DESTRUCTION [I OUT-OF-SERVICE WELL [] GEOPHYSICAL. WELL # 17 SOIL BORING <br /> [1 INSTALLATION XWELL SYSTEM REPAIR [) CROSS-CONNECTREPAIR 11 VAPOR EXTRACTION WELL # <br /> [I New dY Repair H.P. 1 DEPTH PUMP SET FT. FIRST WATER LEVEL� <br /> (TYPE OFF PUMP) i <br /> /` R I <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> €l INDUSTRIAL El OPEN BOTT014 DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING <br /> DOMESTIC/PRIVATE El GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA. OF WELL CASING <br /> []PUBLIC/MUNICIPAL (I DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> [I IRRIGATION/AG [I OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> [I MONITORING GROUT SEAL PUMPED. [I Yes 0 No CONCRETE PEDESTAL BY DRILLER: 11 Yes [I No <br /> APPROX. DEPTH LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTRUCTIONIORILLING METHOD: MUD ROTARY_ AIR ROTARY_ AUGER_ CABLE_ OTHER_ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinancesa <br /> State Laws, and Rules and Regulations of the San Joaquin County. Home owner or licensed agent's signature certifies the.following: "i <br /> certify that in the performance of the work for which this permit is issued, I shall not employ persons subject to WORKMAN'S COMPENSATION.: <br /> Laws of California." Contractor's hiring or sub-contracting signature certifies the following: " 1 certify that in the performance G <br /> of the work or which this permit is issued, I shall employ persons subject to WORKMAN'S COMPENSATION Laws of California." THE APPLICANT <br /> MUST CA 24 OURS IN A V CE IFN All REQUIRED INSPECTIONS AT 1201)488.3423. Complete drawina er area provided. -i <br /> 7 <br /> Signed Ti CI Dat <br /> PLOT PLAN (Draw to Scale) Scale " to <br /> 1. Names 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 alt 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 /> C <br /> J Fi <br /> VL <br /> YPU HE LT Si. VIC <br /> ALT DI ISI N <br /> I <br /> i <br /> r DEPARTMENT USE ONLY <br /> Application Accepted By L� •� __ __ D e Z Area <br /> Grout Inspection By Date Pump Inspection By Date SS <br /> Destruction Inspection By Date Comments: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED EC f1CASH RECEIVED BY DATE PERMITISERVICE REOUEST NUMBER INVOICE , <br />