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APPLICATION FOR WELLIPUMP PERMIT �7 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES A" <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 380, 445 N. SAN JOAQUIN ST., STOCKTON,CA 95201.388 <br /> (209) 468.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete In Triplinte) <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 compliance with San Joaquin County Development Title, Chapter 9-1115 3 and the Standards of San Joaquin County Public Health <br /> Services, Environmental Health Division. nJ <br /> Job Address/or APN# JVA4&_M <br /> city t_Azre/,,/ Parcel Size/APN# Au �V <br /> Owner' Name 6 U2 Address Phone4622�� <br /> Contractor g&.Z4., Address ?X1AV6&r e�" ?41) bOAL iqc&#r dAgVF Phone W<70)q-35-09,5;0 <br /> Sub Contractor Zjj!�Al Address 1645- _0LZ_*!5 Ae,,-dLic# <br /> UeL Phone # <br /> TYPE OF WELL/PUMP: 11 NEW WELL 11 REPLACEMENT WELL El MONITORING WELL # 0 OTHER <br /> [I DESTRUCTION El OUT-OF-SERVICE WELL El GEOPHYSICAL WELL # V.SOIL BORING <br /> El INSTALLATION [I WELL SYSTEM REPAIR [I CROSS-CONNECT REPAIR [I VAPOR EXTRACTION WELL # <br /> [3 New If Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> E3 INDUSTRIAL EI OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING <br /> [I DOMESTIC/PRIVATE El GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA. OF WELL CASING <br /> El PUBLIC/MUNICIPAL [I DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> El IRRIGATION/AG OTHER 0, GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> 0 MONITORING GROUT SEAL PUMPED: [I Yes 0 No CONCRETE PEDESTAL BY DRILLER: 0 Yes El No <br /> APPROX.DEPTH SQ LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTRUCTIONIDRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I hereby certify that I 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, I shalt not employ persons subject to WORKMAN'S COMPENSATION <br /> Laws of California." Contractor's hiring or sub-contracting signature certifies the following: 11 1 certify that in the performance <br /> of the work for which this permit is issued, I shall employ persons subject to WORKMAN'S COMPENSATION Laws of California." THE APPLICANT <br /> MUST CALL 24 HOURS IN ADVANCE FOR ALl REOUIRED INSPECTIONS AT(209)468-3423. Complete drawing at tower area provided. <br /> Signed X Title &222_�7_ Date It' <br /> 147 <br /> PLOT PLAN (Draw to Scale) ScaL& to <br /> 1. Names 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 /> 19T <br /> Pur" 0 JQ(J1 <br /> SNi _1C Hiz., f 901 IN7v I <br /> — LT D"w',", <br /> DEPART USE ONLY <br /> Date Area <br /> Application Accepted By Ada <br /> Grout Inspection By Date Pump Inspection By Date <br /> Destruction Vrgpection By Date Comments: <br /> r <br /> ACCOUNTING ONLY. AID# FACN <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKOICASN RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> CPa 10127 0 <br />