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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUI.N COUNTY PUBLIC HEALTH SERVICES JQ(i ^'1 :.J+lc, I et1 <br /> ENVIRONMENTAL HEALTH DIVISION G <br /> P 0 BOX 398,446 N.SAN JOAQUIN ST, STOCKTON,CA 96201-388 <br /> 12091 4883420 <br /> AOR REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICsmPWW is T'IPUcaWI <br /> Application is here by made to the San Josgifn Ccinty for a permit to construct and/or Install the ,cork descried. This eMlication is <br /> made in compliance with San Joaquin Coulty Oeyelopnent Title, Chapter 9-1115.3 and the Standards of San Joaquin Canty Iwo Health <br /> Services, Environmental NegJth Division. /f/n ^J�/� / -1 7_CY Jl( <br /> Jab AddKTa/or,LPNB l / • L"' I\_-I /l/-f city ^ Parcel Site/APNf <br /> UZY <br /> owner's Mm i 356V fl 04(111,ilt 6,1/1' <br /> 1 Phone r�T•r�!'T— <br /> Contractor (��/( NI(=71 Address 2L]i E/F(�J/J/T/yw LicR�� Phone <br /> hE Contractor Address Lica Phone R <br /> r I j TYPE Or YELt/PUMP; ❑ NEL'WELL (I REPLACEMENT WELL I] MONITORING WELL 1 ❑ OTHER <br /> yl� ❑ DESTRUCTION Q OUT-OF-SERVICE WELL 11 GEOPHYSICAL Wta ■ ❑ SOIL BMIMG <br /> U INSTALLATION (1 WELL SYSTEM REPAIR ArfROSS-CONNECT REPAIR 11 VAP('e EXTRACTION WELL 4_ <br /> FT N. 1[1 Repnir M..P- DEPTH PUMP SET FT. FIRS{ WIER LEVEL_ <br /> (TYPE OF PUMP) I�/S'i AI,L r.p,,l ll/ [ rJ/'• /J h-� N %0 rl.�l'� _ <br /> C�INTHOEO USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ,.J ❑ INDUSTRIAL [] OPEN BOTTOM DIA. OF ALI EXCAVATION DIA. OF CONDUCTOR CASING_ <br /> II DOMSTIC/PRIVATE U GRAVEL PACK/SIZE_ TYPE OF CASING/STEEL/PVC OU. OF WELL CASING <br /> U PUBLIC/MUNICIPAL I] DRIVEN DEPTH OF GROUT SEAL_ SPECIIICATIOR <br /> 'tet` 11 IRRIGATION/AG [] OTHER GROuI SEAL INSTALLED BY_ GROUT BRAND NUM <br /> U MONITORING GROUT SEAL "PED: ❑ Yes D No CONCRETE PEDESTAL BY DRILLER: [] Yes 11 No <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTIWCTIONIORILLING METHOD: MLO ROTARY_ AIR ROTARY_AUGER_._ CABLE_OTHER__ <br /> N <br /> ,l \1 hereby Corti fy that I have prepared this applicatian am that the work will be cone in accordance with San Joa4.Im Canty Or6friances, <br /> State Laws, std Rules and Regulations of the San Joaquin Canty, home owner or licensed agent's signature certlf(es the fotioming: •1 <br /> certify that In the performance of the work for.filch this permit is issued, 1 shall not employ persons sm4jec[ to WAENAMIS COMPENSATION <br /> Laws of Catlfornla." Contractor's hiri rg or cW-cmtraet irg ei 9netvre certifies the fall ovil N: f certify that in the performance <br /> of the work for Mica thio it Is Issued, I -hail employ percmN subject to YONKIUN'S COMPENSATION Laws of California.- T APPLICANT <br /> —� MUST CAIN 2//X�O/UR./S7(M R M E i ELpvEOUIREO INYPFC[IONO AT 2G11p AgJ4D. Conptere drawl DO n lever area provided. _—_�� <br /> Signed X-Xi "'ut Lt.( .Ce Title_ e <br /> PLOT PLAN (Drs. to Scale) Scale_- to <br /> 1. Mame. of at...is or roads nearest to or bounding the property. 4. Location of house sewage dlapoiol system or <br /> 2. Online o: the property, giving dimension end North direction. proposed ..penton of sewage diapo..l systow. <br /> 3. Dimensioned amines mrd Ixation of .-I e.fating and prrgosed 5. Locatim of wells within rodi Ua of 150 ft_ m <br /> strmtures, Inc[uriina covered areas such az pn'.ios, driveways, the property or ad..inin, prep,-ty. <br /> mrd veikz. <br /> is <br /> ZT <br /> L <br /> I . <br /> DEPARTMENT YS[ONLY ''77 <br /> Appm:icatiAccepted BY/ �� Date[ Areal <br /> Grout Inspection By Do,. PUP IosperI mm By <br /> Deetnetlm Inspection BY _ Data _ C.11:_ <br /> ACCOUNTING OMIY: AID# ;AC' <br /> !c\ <br /> PE [011111 FEE rFO AMOUNT NEMITTED 6FC�I MUSH RECEIVED NY DATE IIRWTRENYICE NLOUENT ANSWER INVOICE <br /> 43 goI <br />