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q ?VVl — <br /> a_� APPLICATION f0A WELLlPUMP PERMIT <br /> t� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 SOX 3111,445 N.SAN JOAOUIN ST,STOCKTON,CA N5201-311N <br /> 1209)488.3420 <br /> NON-REFUNDABLE PERMIT EXPM%t$1 YEAR FROM DATE ISSUED <br /> (Daawlstm is T1*UW ) <br /> Application is here by made to the San Joaquin County for a permit to construct and/or install the work described. This appiicstion is <br /> made in compliance with San Joaquin Canty Development Title, Chapter 9-1115.3 and the Standards of San Joaquin county Public Health <br /> Services, Environmental Health Division. /} <br /> Job address/or APWN,�J�` /l1L-LL/1>//t''� city /rtf.�-G. Parcel Size/AP4# d`-'�`•�J <br /> Owner s uua��11T /� 6' .0 tf Address = /� / / Phoni a <br /> Contractor (L 4 �. Address tiyri.ZS iodddUd4b _Ft//JWAia Z90S/0 Ph— <br /> Sub <br /> honeS b Contractor Address Lich_—Phone# <br /> TYPE Of YELL/PUMP: 0 WW WELL REPLACEMENT WELL ❑ MONITORING WELL N [I OTHER <br /> X DES'RUCTION 0 OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL # () 5014 BORING <br /> INSTAi.LATION [) WELL SYSTEM REPAIR O CROSS-CONNECT REPAIR ri VAPOR EXTRACTION WELL N <br /> [1 New 11 Repair N.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) C W"� I) � — u <br /> INTENDED us Tyrf OF ME R24STAUC7I01 9P TION <br /> Q INDUSTRIAL (I OPEN BOTTOM DIA. OF WELL EXCAVATION ZE DIA. OF CONDUCTOR CASING <br /> — C1 i <br /> YDOMESTIC/PRIVATE )(GRAVEL PACK/SIZE,_ TYPE Of CASING/STEEL/PVC PVC. DIA. OF WELL CASING /(/x[7 <br /> 1) PUBLIC/MUNICIPAL p DRIVEN DEPTH Of GROUT SEAL _ SPECIFICATION <br /> [) IRRIGATION/AG 0 OTHER GROUT SEAL INSTALLED BY _ GROUT BRAND NAME_AP.s?4iu%d_1 <br /> [I MONITORING r GROUT SEAL PLMPED: p(Yea [I No CONCRETE PEDESTAL BY DRILLER: 0 Yes 0 No G <br /> APPSOX.DEPTH}_—_ _��'—� LOCKING CHESTER BOX/STOVE PIPE_. <br /> PROPOSED CONSTRUCTIONIOMLLINB METHOD: MUD ROTARY_AIR ROTARY_AUGER,CAGLE_OTHER_ <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinancea,j4,. <br /> State Laws, and Rules and Regulations of the San Joaquin County. Homeowner 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 toWORiOMN'S COMPENSATION <br /> Laws of California.- Contractor's hiring or sub-contracting signature certifies the following: " 1 certify that in the performance <br /> of the work for which this permit is issued, 1 shall employ persons subject to WORKMAN'S COMPENSATION Laws of California." THE APPLICANT <br /> MUST CALL 11 NO iN ADVANCE FOB A QUIRES LN/PECTiONS AT C1O✓}140 13. Complete dr ing at lower area provided. <br /> Signed X / ntla <br /> PLOT PL (Dr t Sule' Scale " to <br /> A. Names of streets or roads nearest to or bounding the property. A. Location of houae sewage disposel system or <br /> 2. Outline of the property, giving dimensions and North direction. proposed expension of sewage disposal systems. <br /> 3. Dimensioned outlines and locatian of all existing and proposed 5. Location of wells within radius of 150 ft. on <br /> structures, including covered areas such as patios, driveways, the property or adjoining property. <br /> and walks. <br /> Li' La <br /> ENT <br /> J JL It 317915S <br /> 4 <br /> a, r,b <br /> •y, 1 ,y C i <br /> T� H lC 5 <br /> /SlO. <br /> 59� <br /> I <br /> DEPARTMENT UBE ONLY I r <br /> n (7 JZ j <br /> Application Accepted <br /> (BArea <br /> �y �•/ qi Date— <br /> Grout Inspection By �l •' '`L1». J Date !_L i Pump Inspection By �'7 Date <br /> c , - 95 �l�' <br /> Destruction Irc�pectian By `� '^� '�'�Lbate ��� Caementa: <br /> j li , glLo`k.t� <br /> ACCOUNTINg ONLY: AID# FACNJ CDC) — y f G <br /> PE CODES FEE INFO AMOUNT IMMITTED G CS ASN RECEIVED BY DATE QUEST WV0iCE <br /> +) 061D 0��0 <br /> 0 1'I iznon 0 <br />