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- r`,�PUCATION EOR WELLIPUMP PERMIT <br /> SAI. ..;AOUIN COUNTY PUBLIC HEALTH SERVICES- <br /> ENVIRONMENTAL <br /> ERVICES ENVIRONMENTAL HEALTH DIVISION w <br /> I P 0 BOX 388, 446 N. SAN JOAOUIN ST., STOCKTON, CA 96201.388 � <br /> (209) 488-3420 [I l l[Fly <br /> NGN-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> ICompleu ie Triplicate) <br /> Application is here by made. to the San Joaquin County for a permit to construct and/or install the work described. This app€ication 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 /> I Services, Environmental Health Division. <br /> Ab Address/or APN#( `T <br /> cityQ Parcel Size/APN#Phone #. <br /> Owner's Name�(1�u� Address -2ucs �] J,cxc -frr��l.ee.c• j'�-z{. �tG - 9,3e- l� <br /> h SQ / <br /> Contractor tS zZnl Q cl Address 1 9/6 A L ic#J1,-L 3 7-3 Phone <br /> 111 -y <br /> Sub Contractor Address Lic# Phone # <br /> TYPE OF WELL/PUMP: ❑ NEW WELL [I REPLACEMENT WELL ❑ MONITORING WELL # C7 OTHER <br /> El DESTRUCTION ❑ OUT-OF-SERVICE WELL [I GEOPHYSICAL WELL # [) SOIL BORING <br /> } [3' INSTALLATION [I WELL SYSTEM REPAIR [I CROSS-CONNECT REPAIR [I VAPOR EXTRACTION WELL # <br /> tl New C-YRepair If.P. DEPTH PUMP SET 144 rFT. r FIRST WATER LEVEL <br /> (TYPE OF PUMP) i <br /> 7 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> .M <br /> 13 INDUSTRIAL [] OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING <br /> &"OMESTIC/PRIVATE [] GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA. OF WELL CASING �- <br /> l7I PUBLIC/MUNICIPAL C) DRIVEN DEPTH Of GROUT SEAL SPECIFICATION <br /> 04 IRRIGATION/AG [I OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> [I MONITORING GROUT SEAL PUMPED: [I Yes [I No CONCRETE PEDESTAL BY DRILLER: [I Yes [I No <br /> APPROX. DEPTH LOCKING CHESTER BOX/STOVE PIPE <br />" PROPOSED CONSTRUCTIONIORILLING METHOD: MUD ROTARY_ AIR ROTARY_ AUGER CABLE___,^ OTHER_ <br /> 4 <br /> v1hereby 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: "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 sub-contracting signature certifies the following: " I 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 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT(2091498-3423. Complete drawing at lower area provided. 4 ,5t �y <br /> Signed X_ F� itle �'L/ Dateli' <br /> I 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 /> Z! 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 wel=ls within radius of 150 ft. on <br /> structures, including covered areas such as patios, driveways, the property or adjoining property. <br /> and walks. <br /> I <br /> i� <br /> I j <br /> p <br /> N r <br /> J � <br /> �Jrd <br /> QA k <br /> ljl' Iti, li 1 r.,i 1,,; ii 4 tiro a <br /> d .i <br /> . , <br /> DEPARTMENT USE ONLY <br /> Application Accepted By e Date—�— r Area tr <br /> Gout Inspection Sy PDate <br /> Pump Inspection By - G« Date <br /> Destruction Inspection By Date Comments: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT RE TTEII HE #ICASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> C 52L <br /> F <br /> I� <br /> 5 <br />