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APPLICATION FOR WELLIPUMP PERMIT / <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERV, Da6a <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201388 <br /> (209) 468-3420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in 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. I,n/ �// <br /> Job Address/or APN# 41, W !� CT/, Y` 1/ City Z, Parcel Size/APN# <br /> Owner's Name^�I 61164 9 . ✓/ Address NA Phone # <br /> Contractor0///w! g /Y/ '5�:/j t:- Address Y Lrt F9 Lic# Phone #5 <br /> Sub Contractor Address Lic# Phone # <br /> TYPE OF WELL/PUMP: 0 NEW WELL 0 REPLACEMENT WELL 0 MONITORING WELL 8 0 OTHER <br /> [I DESTRUCTION 0 OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL # [1 SOIL BORING <br /> /) 0 INSTALLATION [I WELL SYSTEM REPAIR 0 CROSSCONNECT REPAIR 0 VAPOR EXTRACTION WILL # <br /> 0 S.t --- [1 New XRepair H.P. DEPTH PUMP SET �FT. FIRST WATER LEVEL_ <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> (1 INDUSTRIAL [I OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING <br /> '9 DOMESTIC/PRIVATE [1 GRAVEL PACK/SIZE_ TYPE Of CASING/STEEL/PVL DIA. OF WELL CASING <br /> 0 PUBLIC/MUNICIPAL 0 DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> [1 IRRIGATION/AG 0 OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> [1 MONITORING `7 �� GROUT SEAL PUMPED: 0 Yes 0 No CONCRETE PEDESTAL BY DRILLER: [1 Yes 11 No <br /> APPROX. DEPTH ` 15LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTRUCTIONIDRILLING METHOD: MUD ROTARY_ AIR ROTARY_ AUGER_ CABLE_ OTHER- <br /> 5' <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, 6 <br /> State Laws, and Rules and Regulations of the San Joaquin County. Hone owner or licensed agent's signature certifies the following: "I c <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 13 <br /> Laws of California." Contractor's hiring or sub-contracting signature certifies the following: " I certify that in the performance <br /> of the work for which this permit is issued, 1 shall employ persons subject to WORKMAN'S COMPENSATION Laws of California." THEAPPLICANT f <br /> MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT (205)4583423. Complete drawing at lower area provided. <br /> !d <br /> Signed X Title F�5�4;, Date <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 /> cf Yf V1 7 <br /> V072 t 197 <br /> P LIC EAL H 1 RVIJ"S <br /> E VIR N <br /> DEPARTMENT USE ONLY <br /> Application Accepted ByDate Area / <br /> Grout Inspection By Date Pump Inspection By V' Date/4//97 <br /> Destruction Inspection By Date Comments: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO I AMOUNT REMITTED CHEC CASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER EINVOICE1q7 /,J x ' 9l, <br />