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x,, Wit• f j APPLIGATILIN FUR VWLL11Pi1RRP PERMI I <br /> k JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 96201-388 <br /> (209) 468.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Trkplieetel <br />!Application is here by made Jo the San Joaquin County for a permit to construct and/or install the work described. This application is <br /> made in compliance with Sam 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# City !/�.� _ Parcel Size/APN# <br /> Owner's Name Address �e Phoria # <br /> (Contractor 4 Address Lic#'3 7'2,2 •W Phone # <br /> i <br /> Sub Contractor Address Lic# Phone # <br /> I <br />-TYPE OF WELL/PUMP: ❑ NEW WELL 0 REPLACEMENT WELL ❑ MONITORING WELL # (I OTHER <br /> [3 DESTRUCTION 0 OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL # 0 SOIL BORING <br /> INSTALLATION 0 WELL SYSTEM REPAIR. [3 CROSS-CONNECT REPAIR U VAPOR EXTRACTION WELL # <br /> New ❑ Repair H.P. DEPTH PUMP SETFT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION_SPECIFICATIONS <br /> d'[3 INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING <br /> X DOMESTIC/PRIVATE [I GRAVEL PACK/SITE TYPE OF CASING/STEEL/PVC DIA. OF WELL CASING <br /> (3 PUBLIC/MUNICIPAL '(I DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> 4[I IRRIGATION/AG ❑ OTHER GROUT. SEAL INSTALLED BY GROUT BRAND NAME <br /> [3 MONITORING GROUT SEAL PUMPED: D Yes ❑ No CONCRETE PEDESTAL BY DRILLER: [3 Yes [) No <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTRUCTIONIORILLING METHOD: MUD ROTARY_ AIR ROTARY— AUGER, CABLE_ OTHER_ <br /> til 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 licensed agent's signature certifies the following, "1 <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 <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 H IN ADVANCE FO LL REDUIRED INSPECTIONS AT(2051488.3423. Complete drawing at Lower area provided. <br /> Signed X Title ��5 ' Date P I' <br /> PLOT PLAN (Draw to Scale) Scale "-to �? <br /> j1. Names of streets or roads nearest to or bounding property. ~ <br />] g the p pe y. 4. Location of house sewage disposal system or m <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 r <br /> and walks. property Y or adjoining g Property. <br /> . 'P 6 <br /> 1 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By -�cc - D e t t bJ If L Area <br /> f--rte <br /> Grout Inspection By Date' Pump Inspection 8y Date(% <br />'Destruction Inspection By Date Comments: �� J <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK CASH RECEIVED,BY DATE PERMiT1SERVICE REQUEST NUMBER, INVOICE <br />