Laserfiche WebLink
APPLICATIUN kUiC MYtLLfPUMIP PkRIVIIT <br />("11,4111 JOAauiw COUNTY PUBLIC HEALTH SERVICL <br />ENVIRONMENTAL HEALTH DIVISION <br />P 0 BOX 388, 445 N. SAN JOA[IUIN ST., STOCKTON, CA 85201-388 <br />(208) 488.3420` <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete Is Triplicate) <br />Application is here by made to the San Joaquin County for a permit to construct and/or install the work described. This application is <br />made in compliance with San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br />Services, Environmental Health Division. <br />Job Address/or APN# 702 O - to ot City �� r _ Parcel Size/APN# <br />Owner's Name Address 1% Phone # <br />Contractor c- Address Lic ��L,, _Z _ Phone # t <br />Sub Contractor Address Lic# Phone # <br />TYPE OF WELL[PUMP: [] NEW WELL <br />[] REPLACEMENT WELL <br />[] MONITORING WELL # <br />[] OTHER <br />E] DESTRUCTION <br />[1 OUT-OF-SEkVICE WELL <br />[] GEOPHYSICAL WELL # <br />[] SOIL BORING <br />INSTALLATION <br />[1 WELL SYSTEM REPAIR <br />E1 CROSS -CONNECT REPAIR <br />[] VAPOR EXTRACTION WELL iR <br />New [1 Repair <br />H.P. <br />DEPTH PUMP SET <br />.FIRST WATER LEVEL <br />(TYPE OF PUMP) <br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br />[] INDUSTRIAL 0 OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING <br />DOMESTIC/PRIVATE [] GRAVEL PACK/SIZE TYPE Of CASING/STEEL/PVC DIA, OF WELL CASING <br />[] PUBLIC/MUNICIPAL .E] DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br />[] IRRIGATION/AG [] OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME <br />[] MONITORING GROUT SEAL PUMPED: [1 Yes [1 No CONCRETE PEDESTAL BY DRILLER: [] Yes [] No <br />APPROX. DEPTH LOCKING CHESTER BOX/STOVE PIPE <br />PROPOSED CONSTRUCTIONiDRiLLING METHOD: MUD ROTARY— AIR ROTARY! AUGER_ CABLE_ OTHER__,__ 4` ` <br />1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Z <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 subcontracting signature certifies the following: 11 1 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." TAE APPLICANT <br />MUST CALL 24 H IN AOVANCE FO LL REQUIRED INSPECTIONS AT (208) 4418.2423. Complete drawing at lower area provided. <br />Signed Title 20� S Date F <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 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 />■■ ■■■■■ ■■ ■ ■■ ■ ■■■ ■■ <br />■■■ ■■ ■ <br />■■■ ■■■ ■ <br />FAC# <br />PE CODES FEE INFO <br />AMOUNT REMITTED <br />CHECK CASH RECEIVED BY <br />DATE PERMITISERVICE REQUEST NUMBER INVOICE <br />�' <br />■■■■iii■■■■■■■■i■■r���■■■■■■■■■■■■■■ <br />DEPARTMENT USE ONLY <br />.. -.� � -ter..- a <br />Cly D -e - - .t�(•cKr-ea- <br />-A <br />a <br />App[-icatforn Accepted By c� c 1 i' Asea <br />Grout Inspection By DatePump Inspection By Data/ <br />Destruction Inspection By. <br />Date Comments; <br />ACCOUNTING ONLY: <br />AID# <br />FAC# <br />PE CODES FEE INFO <br />AMOUNT REMITTED <br />CHECK CASH RECEIVED BY <br />DATE PERMITISERVICE REQUEST NUMBER INVOICE <br />�' <br />