Laserfiche WebLink
APPLICATION FOR INELLIPUMP PERMIT <br /> rI SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION Now, <br /> P 0 BOX 399,446 N.SAN JOAQUIN ST.,STOCKTON,CA 95201.388 <br /> (209)489.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> lComplate is Triplieate] <br /> Application is here by made to the Sen 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 Sen Joaquin county Public Health <br /> Services, Environmentat Health Division. L L <br /> Job Address/or APNN36/ k). '/Ira.t bL e &W. �/'�11T. City %a(!I/ Parcel Size/APNX <br /> Owner's Name f R.bIIG I�JOr�y Address.J� Q t�� 5 tp o Phone F <br /> Contractor P.f fi. Address �Or l l-/T.Lic# , Z1 a phone N�67-79� .Z <br /> Address 15 TV <br /> Sub Contractor _ Lic# Phone # <br /> TYPE OF HELL/PUMP: [I NEN WELL 11 REPLACEMENT WELL 11 MONITORING WELL N I] OTHER <br /> XDESTRUCTION U OUT-oF-SERVICE WELL 11 GEOPHYSICAL WELL M 11 SOIL BORING r , <br /> E] INSTALLATION 13 WELL SYSTEM REPAIR [] CROSS-CONNECT REPAIR 11 VAPOR EXTRACTION WELL A' L A 1 <br /> (TYPE OF PUlMP) 11 New [] Repair N.P. DEPTH PIMP SET FT. FIRST WATER LEVEL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> 11 INDUSTRIAL 11 OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. Of CONDUCTOR CASING 7�' <br /> 11 DOMESTIC/PRIVATE I1 GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA. OF WELL CASING <br /> [1 PUBLIC/MUNICIPAL (1 DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> 11 IRRIGATION/AG 11 OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> 11 MONITORINGGROUT SEAL PIMPED: 13 Yes [] No CONCRETE PEDESTAL BY DRILLER: [I Yes 11 No <br /> APPROX.DEPTH as 74f, LOCKING CHESTER 9OX/STOVE PIPE <br /> PROPOSED CO NST RUCTIONIORIILING METHOD: MUD ROTARY_AIR ROTARY AUGER CABLE OTHER <br /> r b <br /> 1 hereby cirtiff that 1 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, 1 shall not eeptoy 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 shell employ persons subject to WORKMAN'S COMPENSATION Laws of California.*' THEAPPLICANT <br /> MUST CALL 24 HO S IN ADVANCE FOR ALL REDUIRED INSPECTIONS AT 92001 481.5423. Complete drawing at lower area provided. <br /> Signed X � Title —Dateq y S <br /> PLOT PLAN (Draw to Scale) Scale " to <br /> 1. Nerves 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 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 /> 7 �PAIIJKENT USE ONLY <br /> Application Accepted By Dat PT !� Area <br /> Grout Inspection By Datdf u• Pump Inspection By Date <br /> Destruction Inspection By Date Comments: <br /> —71 ACCOUNTING ONLY: AID# FACN <br /> PE CODES FEE INFO AMOUNT REMITTEDCH K CASH RECEIVED BY DATE PERMIT►SERVICE REQUEST NUMBER INVOICE <br /> to 0 sVq <br />