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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388,4U N.SAN JOADUIN ST„ STOCKTON.CA 16281-M <br /> MCI)4584UD <br /> NON•REFYNOAILE ff MII EXFIREN 1 YEAR FROM DATE IfEUER <br /> OwwWr r T 4 -I <br /> Application Is here by Bade to the San Joaquin county for a permit to construct and/or install the work described. This application Is <br /> made in coApliance with Sen Josquin County Develapment Title, chapter 9-1115.1 and the Standards of Sen Joaquin County Public Health <br /> services, Environmental Health Division. / <br /> Job Address/or APN# ?.5?ro -3-r, ��• �� aNrf City ' /(� Parcel Size/APNS <br /> Owner's Name Sl . nJ.A.✓ Address, -?_CLsLsr•.• w•%+1yr �Ya�C4� 4r37L Phone fqr�,� <br /> Contractor. ?cTjgL&Mrje YLJre✓ Address Phar i --k/Db <br /> Sub Contractor Address <br /> r '� S��(o Lic# Phone 0 <br /> TYPE OF WELL/PUMP: U NEW WELL h REPLACEMENT WELL I] MONITORING HELI A 17 DYNES <br /> W <br /> V DESTRUCTION [] mg-Of-SERVICE WELL II GEOPHYSICAL WELL A C SOIL BORING p <br /> 17 INSTALLATION (I WELL SYSTEM REPAIR O CROSS-CONNECT REPAIR (I VAPOR EXTRACTION WELL B <br /> sut U New repair N.P. /6—_ DEPTH PUMP SET41L I_fI. FIRST WATER LEVEL_/ <br /> (TYPE OF PIMP) <br /> NTTEROEO USE TYPE OF MLL CONItTWCTION IMIFICATTONi <br /> ti INDUSTRIAL 0 OPEN BOTTOM DIA. OF YELL EXCAVATION OSA. OF CONDUCTOR CASING 6 <br /> [] DOMESTIC/PRIVATE I] GRAVEL PACs/SIZE TYPE OF CASING/STEEL/DVC DIA. OF YELL CASING <br /> p KMLIC/R.INICIPAL 11 DRIVEN DEPTH OF GROUT SEAL SPECIFICATION Ck <br /> II IRRIGATION/AG U OTHER GROUT SEAL INSTALLED BY GROUT BRAND NNE Io <br /> U MONITORING GROUT SEAL PUPED: 17 Yes [I No CONCRETE PEDESTAL BY DRILLER: 11 Yes El HO d <br /> APPROX.BOTH LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONBTRUCTICNIDMLUNG NFINgD: MLD ROTARY__AIR ROTARY_AUGER_CABLE, DTWR _ <br /> 1 hereby certify that I have preper th s application and that the work will be dote in accordance with San Joaquin County Ordinonees, <br /> State Laws, and Rules and ReguLationa of the Son Joaquin Canty. Hamm owner or Licensed agent's signature certifies the following: 01 <br /> certify that in the performance of the work for which this permit is issued, 1 shsLL not esplay persons subject to UORKNAN'S COMPENSATION <br /> Jews of Californis.w Contractor's hiring or sub-cont ractins signature cer•tifles the following: a I certify that in the performance <br /> of the work for which this permit is issued, i shell employ persons subject to YORKMNIS COMPENSATION Lows of California." TME APPl1CANT <br /> MIT CALL 24 N77-,,42a, <br /> ADVANCE FOR ALL REQUIRED N15PECFIOMB AT 12411 U11- 22. Complete drawing at lower area provided. <br /> Signed X A _ Title, 01VAJ-0r Date 5,4, <br /> PLOT PLAN (Draw to Scale) scale • to <br /> 1. Messrs of streets or roads merest to or barding the property. 4. Location of house sewage disposal system or <br /> 2. Outline of the property, giving dimensions and North direction. proposed expeneion of sewge disposal systems. <br /> 3. Dimensioned outlines end location of aLL existing and proposed 5. Location of wells within radius of 150 It. on <br /> struetures, including covered areas such as patios, driveways, the property or adjoining property_ <br /> and walks. <br /> aw t <br /> r' <br /> s <br /> JUA <br /> jIV ENC0 <br /> !A <br /> DEPARTMENT USE ONLY <br /> Application Accepted ByS�o Dates Area <br /> Grout Inspection Dy Date Pulp Inspection By z!i <br /> Destruction Irw4wetion By Date Consents: <br /> ACCBIIBTINg ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED tll BM BECEINEB By DATE TiBEJeVICE REOUEBT NIiNAEN IDVBICE <br /> 3 o d ,00 17 q 9�- o o �a19 <br />