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APPLICATION FOR WELLIPUMP PERMIT <br /> .,AN JOAQUIN COUNTY PUBLIC HEALTH SERVICE_ <br /> ENVIRONMENTAL HEALTH DIVISION �) <br /> P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201.388 <br /> (209) 468.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <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. <br /> Job Address/or APN# r D O w_ Z6:,, 2 City ` 61- 1 Parcel Size/APN# <br /> Owner's Name <br /> �iccviAC C_ le Address T I� ct ,{ �-(U'e— Phone # <br /> � G <br /> Contractor Address Lic# Phone # <br /> Sub Contractor Address Lic# Phone # <br /> TYPE OF WELL/PUMP: [) NEW WELL [I REPLACEMENT WELL [I MONITORING WELL # [I OTHER <br /> [I DESTRUCTION Y OUT-OF-SERVICE WELL [) GEOPHYSICAL WELL # [I SOIL BORING <br /> INSTALLATION (I WELL SYSTEM REPAIR [I CROSS-CONNECT REPAIR [) VAPOR EXTRACTION WELL # <br /> New [I Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> [) INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING <br /> [) DOMESTIC/PRIVATE ❑ GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA. OF WELL CASING <br /> PUBLIC/MUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> [I IRRIGATION/AG [I OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> (I MONITORING GROUT SEAL PUMPED: ❑ Yes [I No CONCRETE PEDESTAL BY DRILLER: ❑ Yes [) No <br /> APPROX. DEPTH LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTRUCTIONIORILLING 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 shall not employ persons subject to WORKMAN'S COMPENSATION <br /> Laws of California." Contractor's hiring or sub-contracting signature certifies the following: 11 I 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 Q) <br /> MUST CALL IN ADVANCE FOqp ALL DUIRED INSPECTIONS AT (209)488.3423. Complete drawing at Lower area provided. O <br /> X signed X <br /> � - ►Q- Title Date <br /> PLOT PLAN (Draw to Scale) Scale " to <br /> 4. Location of house sewage disposal system or <br /> 1. Names of streets or roads nearest to or bounding the property. ro sed expansion of sewage disposal systems. <br /> 2. Outline of the property, giving dimensions and North direction. P Po ex P <br /> 5. Location of wells within radius of 150 ft. on-"<3. Dimensioned outlines and location of all existing and proposed the property or adjoining property. <br /> structures, including covered areas such as patios, driveways, <br /> and walks. <br /> w L <br /> E NT <br /> ® u�{ <br /> f t' C 11 E <br /> IL,L 99 <br /> SA J AQ liy OU 4TY <br /> i't'� dTA N�� ,Li�i DIV' 10 <br /> DEPARTMENT USE ONLY ` f <br /> Application Accepted By <br /> Dat A) <br /> / Area I LTJ <br /> Grout Inspection By <br /> Date Pump Inspection By Date <br /> D struction Inspection By � Date Comments: ✓a k-. <br /> ^2� {moi!'�c��-✓✓t-c o <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTEDO"ECIICASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> �{3. (v� o• ca t� <br /> 4 1501-3 <br />