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APPLICATION FOR INUMPUMP PERMIT - - - - <br /> SAP JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVHIOMMEMTAL HEALTH DIMION <br /> P O BOX 38% 446 11. BAN JOAQUIN ST, STOCi(TON,CA SMI-388 <br /> M)4684=8 <br /> IMI-RMA R FROM Te <br /> M41000 IN TrWICE r} <br /> Application is here by made to the Sen Joaquin County for a permit to earmtruct and/or install the work described. This application is <br /> made in co=mpliance with San Joaquin Canty DevelTitie, Chapter 9-1115.3 and the Standards of Sen Jompfn County Ftblic Health <br /> Services, Fanvirormantal Health Division. 43± 100 <br /> Job Addressor APN# t 2 l 040 — ) Cf C� I D apt C Tircet Size/APO <br /> 0 <br /> OwnerFs Memo res= # <br /> Contractor o`G �' Address ` z <br /> Sub Contractor i Ax G T Address Lid 22 Phare 9� �� z G <br /> 93 Ar !q14e5;3 6 <br /> TYPE OF WELLAMAfR, p NEU WELL [I REPLACEMENT WELL II MONITORING WELL # [1 OTWI <br /> [I DESTRUCTION [I OUT-OF-SERVICE WELL n GEOPHYSICAL WELL f )(VAIL BRING <br /> [3 INSTALLATION d WELL SYSTEM REPAIR p CROSSCONNECT REPAIR D VAPOR WRACTION WELL * <br /> a New G Repair H.A. DEPTH PIAS SET______". FIRST YATER LEVEL <br /> (TYPE OF PUMP) <br /> Q)iST®DEA DBe Me OF WM D 8 D <br /> 1L1 p INDUSTRIAL [I OPEN BOTTOM DIA. OF WELL ExGYATION l DIA. OF COND=OR CASING YJ Ar _ <br /> p DOMESTIC/PRIVATE p GRAVEL PACX/SIZ► TYPE OF CASITNG/STEEL/PYC DIA. OF WELL CASING <br /> PUBLICfMUKICIPAL O DRIVEN DEPTH OF GROUT SEAL_ at J,bg2nj, SPECIFICATION, WX <br /> 13 IRRIGATION/AG 13 OTHER GROUT SEAL INSTALLED BYT GROUT BRAND NAME;„ T <br /> 13 MONITORING aRMIT SEAL PUKM: 13 Yea [I No CONCRETE PEDESTAL BY DRILLER-:XTes 13 Mo P n <br /> APPIWIL I)EPIB tO O K (DW6LZ$) LOCKING CHESTER BO1I/S7OVE PIPE V <br /> PROPOSEO CDaBTRUCTIONMRILLDID METHOD: MUD ROTARY, AIR ROTARY_ AUGER, CABLE_ OTHER <br /> ( n 1 hereby cern ti <br /> that I have red this a licatio,� and that the work will be dans in accordance with San Joaquin County Ordinances,` <br /> State , and Rules and Regulations of the sen Joaquin County. Hama 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, I shall not employ persons subject to WORK14AM'S COMPENSATIdL9 <br /> Laws of California.° Contractor's hiring or sub-contracting signature certifies the following: ° 1 certify that in the performer <br /> +�1 of the bark for which this permit 1s issued I shall employ persons subject to WORKPM'S COMPENSATION Laws of California.= T'HEAMICART� <br /> MOT CALL Zi HOURS IN -3�LZ <br /> ADVANCE LL RE MWICTIOES AT i.`ge1i. Complete drawing at lower area provided. <br /> Signed XDate <br /> — / 71t1e <br /> P PLAN (Draw to Scale) Scale o to <br /> 1. Names of streets or roads merest to or bounding the property. 4. Location of house sawage disposal system or <br /> Z. Outline of the property, giving di Ions and North direction. proposed exparmlan of sewage disposal systems. <br /> 3. Dimensioned out Lines and location of all existing and proposed S. Location of wells within radius of 150 ft. an <br /> structures, including covered areas such as patios, drivehoys, the property or adjoining property. <br /> and walka. - <br /> � 1 o, - -- Iso-+ . - ° <br /> Ate LXR57H <br /> R AD <br /> g Tyt 0 . <br /> --a <br /> sul U4 <br /> AN — <br /> _ _ 1 •� • . <br /> !• PR� 0.'N 1MLT00 0 <br /> i�al< g �1r1V11.st I4411,5144. 00 <br /> , . LE�►EIuD <br /> I <br /> /P Pumping u�1 $ap-�hKo <br /> Station <br /> G� <br /> DEPANKINIT JIBE GUY Q I <br /> Appilcetion Accepted By Date O r Area <br /> � Gy <br /> Grout Inspection F.y_? t/l_ Date ! Pump Inspection By Date <br /> Destruction Impaction By. Date Comments: <br /> ACCOUIFIR.0 ONLY: AID# FAC# <br /> PE WI 00 FEE MFO ARODRT BWTTED CHECKCABN REi EO BY DATE IFE MiTjSERM ROUT RUMBER GIVIII►EV <br /> nO <br /> 0 3� <br /> D � - <br />