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APPLIC' IN FOR VVELLIPUMP PERMIT - -- - - <br /> SAN JOAOUWRamUNTY PUBLIC HEALTH SERVICES ,A. <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388,448 N.SAN JOAOUIN ST, STOCKTON,CA 98201388 <br /> (2091 4883420 <br /> — NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (CespNb h Trplkstal <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 cmpLiame with San Joaquin County Development Title, Chapter 9-1115.1 and the Standards of Ben Joaquin County Public Health <br /> Services, Environmental HeaLth p Division. v� <br /> — Job Address/oor7 APNN 1_3:1 S 0 7/ A F`-0. City K1 Parcel Size/APNN <br /> Owner's Name/ Address J—" — - Phone A36 ^ /O 6 <br /> Contractor Address Lich /G 1.77 Phone #���r"977o.Jf' <br /> rSub Contracto � Address Lick Phone N <br /> r <br /> TYPE OF YELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL D MONITORING WELL N ❑ OTHER <br /> D DESTRUCTION [I OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL # D SOIL BORING <br /> — D INSTALLATION D WELL SYSTEM REPAIR D CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL #_ <br /> Lr New D Repair X.P. 1-49 DEPTH PUMP SET li?7/ T. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> .� INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> D INDUSTRIAL D OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING <br /> 9 <br /> LB'DOIEST IL/PRIVATE D GRAVEL PACK/512E_ TYPE OF LASING/STEEL/PVC DIA. OF WELL CASING � <br /> D PUBLIC/MUNICIPAL 11 DRIVEN DEPTH OF GROUT SEAL SPECIFICATION 9 <br /> — D IRRIGATION/AG D OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> D MONITORING GROUT SEAL PUMPED: D Yea IT No CONCRETE PEDESTAL BY DRILLER: ❑ Yea D No <br /> APPROX.DEPTX LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTRUCTIONIORILLING METHOD: MUD ROTARY_AIR ROTARY_AUGER_CABLE_OTHER_ C <br /> I hereby certify that 1 have prepared this appL!cat ion and that the work will be done in accordance with San JOawin County Ordinances, <br /> State Laws, and Rules and Regu Latiom, 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, 1 shall not esiploy persona subject to WORKMAN'S COMPENSATION <br /> Laws of California." Contractor's hiring or subcontracting signature certifies the following: a 1 certify that in the performance <br /> — of the Work for which this Permit is issued, I shall eaploy persons subject t0 WORKMAN'S COMPENSATION Laws of California." THE APPLICANT <br /> MUST CALL E4 HOURS IN ADVANCE <br /> rFOR <br /> ,ALLLL REQUIRED INSPECTION&AT 1209)445425. Complete <br /> /drawing eat-Low-er�area provided. /-5..gs <br /> Signed X �""' _ H13itle� Date�—PYt <br /> PLOT PLAN (Draw to Scale) Scale" to <br /> wee 1. Nerves of streets or roads giving <br /> to or boarding the property. 6. proposed ex house sewage disposal system or <br /> em <br /> 2. Outline ne the property, Location <br /> n ofasom and North direction. proposed of welne ls <br /> of sewage radius <br /> 1 system. <br /> 3. structures, <br /> outlines and local son of alp as sung and proposed 5. Location of wells Wsthin radius y 150 ft, on <br /> structures, including covered areas such as patios, driveways, the property or adjoining property. <br /> and walks. <br /> 17 <br /> a <br /> DEPARTMENT USE ONLY Oppppp <br /> — <br /> Area <br /> Application Accepted BY _ t <br /> Grout Inspection 8Y Date Pump Inspect. B y Day-4 <br /> Destruction Inspection BY Date Comments: <br /> a. <br /> ACCOUNTLNO ONLY: AID# I FAC# <br /> PE CODES FEEIMFO AMOUNT REMITTED CHE #ICA&H RECEIVED BY GATE PERMITISERVICE REDDEST MVM' <br />