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*; APPLICATION FOR WEMPUMP PERMIT i <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES " <br /> ENVIRONMENTAL HEALTH OIV15!ON <br /> ' P Q BOX M. 446 N.SAN JOAQUIN ST., STOCKTON.CA 95201-388 <br /> 1209) 688.34211 <br /> NO111EFUNDAru PERINT E1IPIP.FS 1 Y AR FROM DATE ISSN - <br /> . - ICamPiI In Tt bliea[s! <br /> Application is here by made to the San Joaquin County for a permit to construct and/or instar! the work described. This application ix <br /> rade <br /> In compliance with.Sen Joaquin County Development 'itle, Chapter 9.1115.3 and the Standards of Ser. Joaquin County Public Health <br /> Services, Fnvfrormental Health nivision. <br /> - <br /> Job Address/or APNp /rC, ( �'(-`w tilt/ (r��lF ff•ilr � i <br /> City Parcel Si:e/APMa <br /> Owner's Namef.r.j::/� .���f c/C-rl..i Address .��fs/'I'j <br /> r - - Phone @ <br /> Contractor > f•.•�+-y= t Addres5�'L'r'�� ��� Licp ' t . <br /> p Phone 0 <br /> Sub Contractor 't~: C•♦ ( {JI}, ( Address LICtl__ phony i, <br /> TYPE OF WELL/PUMP: •{y NEN WELL [] REPLACEMENT WELL (I .MONITOI WELL N — 0 OTHER <br /> r (r DESTRUCTION ❑ OUT-OF-SERVICE YELL 11 GEOPHYSICAL WELL # 11 SOIL BORING <br /> _ (1 INSTALLATION (] WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR [] VAPOR EXTRACTION WILL N <br /> a <br /> •Z_'`'r'• EJ.r.New (I Repair X.P. S DEPTH PUMP SET FT. FICST LATER LEVEL _ <br /> (TYPE OF PUMP) <br /> 00 <br /> i r��NpFO LIFE T aF WE[! CDN-Sl?UCTiON SPECIFICAT!OUS ()1 <br /> A O- <br /> (1 INDUSTRIAL (1 OPEN BOTTOM DIA. OF WELL EXCAVATION_ � DIA- OF tikl0UiT011 CASING_ <br /> YDOMESTIC/PRIVATE VtGRAVEL PACK/SIZE TYPE OF CASINGISTEEL/PVC� CIA. OF WELL CASING <br /> 11 rtIBLIC/MUNICIPAL 11 DRIVEN DEPTH OF GROUT SEAL %X11 SPECIFICATrow ['� <br /> i ❑ IRRIGAT[OI H OTHER GROUT SEAL INSTALLED BY_. GROUT BRAND NAME <br /> [] MONITORING GROUT SEAL PUIMPED:�12-Yrs (] No CONCRETE PED55TAL BY DRILLER• Yes [] Me W <br /> ! <br /> APPROX.DEPTH a�4' LOCKING CHESfEP, BOX/STOVE PIPE �1 <br /> PROPOSED CONSTBUCTIONIOPILLINO HET"07 13)D POTARY._Z AIR ROTARY_ AUGER CABLE_ OTHER ' <br /> 1 hereby certify that 1 have prepared this application and that the workwi[L t•e done sn accordince with San Joaquin County Ordineners, ! <br /> i state Laws, and Rutes and Regutations of the San Joaquin County. Now owner or licensed agert's signature certifies the followfngt It <br /> certify thct in the performance of the work far which this permit is issued, 1 shsLS net employ persons subject to WORKKAN'S COMPENSATION 1" <br /> Laws of Ca(ifornfa." Contr9CcoNa 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 erploy persons subject to YORKNAN'S COMPENSATION Laws of California.- THEAPPLICANT ! <br /> MUST CALL 24 HOURS IN ADVANCE FOR All REQUIRED INSPt:CTIONS AT(1081 488.3421. CoI drawing at lower area provided. ; <br /> I / I <br /> Signed X,�'�� /� - Title t`���✓ �r OetlG' <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 /> j' 2. Outline of the proi-erty, giving dinien3ions and North direction, prOpoAed expansion of sewage dispose systems. <br /> j 3. Dimensioned outlines and location of all existing and p oposed .5. Locotion of wells withrn radius of 150 ft, on <br /> d <br /> structures, incLudfns• covered areas such as patios, driveways, the prOparty or adjoining property. 1 <br /> and walks. <br /> f <br /> i � A <br /> 'AN JW Ll l C UrV Y <br /> -71� 1 <br /> mum <br /> $. r <br /> I t <br /> t <br /> - CEPARTILENT USE DNt'i L <br /> { Appllcatlon A"epted NY C. Date <br /> � r l <br /> Grout Inspection By De!e- .iV �"L7PP Inspection BY-4 <br /> Destruction inspection By Date Comments:_ ft <br /> ACODUNTINO ONLY: AID1! FACN <br /> PE COC12 FEE INFO AIIOUXT REMITTED CHECic CASH RECEIVED BY DA7f PERUMSEDYICE REQUEST NUMBER INVOICE <br /> 31/610 <br />