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APPLICATION FOR WELLIPUf' nERMIT <br /> SAN JOAOUIN COUNTY PUBLIC 1 A SERVICES <br /> ENVIRONMENTAL HEALTH DTTfSION <br /> P 0 BOX 388,446 N. SAN JOAUUIN ST., STOCKTON,CA 96201"388 <br /> (209)460"3420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete is Tripl'ieatel <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. J <br /> Job Address/or APN#,2 i jn2 �- �_ r(,r /4 c City �Q_c.y Parcel Size/APN# c <br /> Owner's Name M%-;-il �lf`�' / Address �� J=(, �i r L-iy!fly Phone # f ,L-'t�-. ZDft— <br /> ,�(/-� / y 7 <br /> Contractor J_'i'_LZf /'�/l/i.nom Address i ilr/ S' /,/, 6i- ,, Lich! y�t1 r(�_- Phone # <br /> Sub Contractor Address Lic# Phone # <br /> TYPE OF WELL/PUMP: XNEW WELL [3 REPLACEMENT WELL [3 MONITORING WELL # [) OTHER <br /> [) DESTRUCTION ❑ OUT-OF-SERVICE WELL [) GEOPHYSICAL WELL # () SOIL BORING <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL # <br /> (3 New () Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS tf <br /> _[7 INDUSTRIAL [] OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. Of CONDUCTOR CASING 0 <br /> ry�DOMESTIC/PRIVATE "�"LRAVEL PACK/SIZE��" TYPE OF CASING/STEEL/PVC DIA. OF WELL CASING y1^J, <br /> (3 PUBLIC/MUNICIPAL (3 DRIVEN DEPTH OF GROUT SEAL "/�71' SPECIFICATION ``//-- l' <br /> [) IRRIGATION/AG ❑ OTHER GROUT SEAL INSTALLED BY - GROUT BRAND NAME r yXP <br /> [) MONITORING GROUT SEAL PUMPED: Yes •I) No CONCRETE PEDESTAL BY DRILLER: [3 Yes "0 <br /> APPROX.DEPTN 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 Ordinances, <br /> State Laws, and Rules and Regulations of the San Joaquin County. Home owner or Licensed agent's signature certifies the following: "] rY <br /> certify that in the performance of the work for which this permit is issued, I shalt not employ persons subject to WORKMAN'S COMPENSATION <br /> Laws of California." Contractor's hiring or subcontracting signature certifies the following: " I certify that in the performance'1 <br /> of the work for which this permit i issued, I shall employ persons subject to WORKMAN'S COMPENSATION Laws of California." THEAPPLICANT <br /> MUST CALL =HIDIANCE F R L REOUIRED INSPECTIONS AT(209)466.3423. Complete drawing atTer area provided. <br /> Date <br /> Signed X pp <br /> Title <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 welts within radius of 150 ft. on <br /> structures, including covered areas such as patios, driveways, the property or adjoining property. <br /> and walks. PAYMENT <br /> JGUI CO NTY <br /> :ALT. SF ICE <br /> ALT I DIV 10h <br /> b <br /> t I rt <br /> DEPARTMENT USE ONLY <br /> Date 7- Area <br /> p (� / <br /> Application Accepted By <br /> �CL f QyG f i 1�7� <br /> Grout inspection By �' ~A`"1'�'`�"'�"7� ? Date /-I C `l 2 Pump Inspection By Date <br /> Destruction Inspection By <br /> Date Comments: /o (Y7 C�lu <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEEINFO AMOUNT REMITTED CHECK ASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> 1,40 .CC) z15 -71 A) o S P- c X 2 9 3 o4c)AV, <br />