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APPLICATION FOR WELLIPUMP PERMIT <br /> ♦wN JOAOUIN COUNTY PUBLIC HEALTH SERVICES„ <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 446 N. SAN JOAOUIN ST., STOCKTON, CA 96201-388 <br /> (2091468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> Iss <br /> Application is here by made to the San Joaquin County for Gaperrmit nto con�Trwlwstruct 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. n <br /> Job Address/or APN# 3- ��+h mac`/ <br /> Chf/S.vWq,d <br /> e City 19%4tL Parcel Size/APN# <br /> Owner's Name Cnal Address 35zoo 5, r+ K ChC,, Wy r` <br /> //�� RryL{ Phone # RAS-9y67 <br /> Contractor FI�"cw(&� Ge• - kI I Address 15o lu . 54-c Lic# <br /> � 7 cy phone # 556 -02b4 <br /> Sub Contractor1 -A�h-hq,I I D�;I I Lig Address too N ((0 �v 1 PhoneCIl6 8Sl-?-z-g <br /> TYPE OF WELL/PUMP: [] NEW WELL [] REPLACEMENT WELL [] MONITORING WELL # [3 OTHER <br /> [] DESTRUCTION 11 OUj[�-OF1-SE IC ELL [] GEOPHYSICAL WELL # SOIL BORING 25' <br /> U INSTALLATION 11 WE(Q SfYS M AIR (I CROSSCONNECT REPAIR [] VAPOR EXTRACTION WELL # <br /> (TYPE OF PUMP) _ <br /> C3 New [3 Repair H.P. <br /> 1 VVV DEPTH PUMP SET FT. FIRST WATER LEVELw l5 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> p I� <br /> (] INDUSTRIAL [] OPEN BOTTOM DIA. OF WELL EXCAVATION [) DIA. OF CONDUCTOR CASING <br /> (] DOMESTIC/PRIVATE U GRAVEL PACK/SIZE_ TYPE OF CASING/STEEL/PVC DIA. OF WELL CASING <br /> i <br /> [] PUBLIC/MUNICIPAL C] DRIVEN DEPTH OF GROUT SEAL 25 SPECIFICATION <br /> ❑ IRRIGATIDN/AG [I OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME iN+/ond <br /> fX MONITORING GROUT SEAL PUMPED: [] Yes WNo CONCRETE PEDESTAL BY DRILLER: [IYes [] No[ nr <br /> APPROX.DEPTH ZS 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 wi Ll 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: " 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." THEAPPLICANT <br /> MUST CALL 24 HOW IN ADVANCE FOR ALL REOUIRED INSP CTHINS AT (201)468.3423. Complete drawing at Lower area provided. <br /> Signed X <br /> Title St AFF Geolo$i7)T DateLq)a/SS <br /> PLOT PLAN (Draw to Scale) Scale " 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 /> o K ' <br /> I IL11i——————— <br /> DEPARTMENT USE ONLY /- <br /> Date 0 b-3 Area <br /> Application Accepted By <br /> Grout Inspection By U'-(% ete/6Punp Inspection By Date <br /> Destruction Inspection By Date Comments: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> O <br /> 3 4 � l}a �� vv�� /o 7-5 1 / <br />