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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> 6. <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 446 N. SAN JOAOUIN ST.,STOCKTON,CA 95201388 <br /> (209)468.33420 <br /> LNONREFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> ICompkte in Tripikstal <br /> Ipplicetion is here by made to the San Joaquin County for a permit to construct and/or install the work described. This application is <br /> ;,ie in compliance with San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br /> �`` vices, Enviroranental Health Division. �f/]//�f / <br /> ` Address/or/RALPN# l 0e--41 9�rT S . l4, ^14 ed �L �ciity Fr I✓c C Parcel SiZe/APN# � 2-V/T•' L� V <br /> lumen's Name 13 a A3c 1­6 r Ar yu e— Address PQ AV A 15'4'r N/ES i SAf my/ Ph ne # 3 <br /> ttractor C t,4 1'k 1 J=LL TM/t Address 202V F. (Ahl7r/' Lia# 371190 Phone # VU-Z7/ <br /> ab Contractor Address Lic# Phone# <br /> 'E OF WELL/PUMP: IT NEW WELL ❑ REPLACEMENT WELL IT MONITORING WELL # ❑ OTHER <br /> &AESTRUCTION IT OUT-OF-SERVICE WELL IT GEOPHYSICAL WELL # ❑ SOIL BORING <br /> ama ❑ INSTALLATION O WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR [3 VAPOR EXTRACTION WELL #_ <br /> [I New ET Repair N.P. DEPTH PIMP SET FT. FIRST WATER LEVEL_ <br /> 'TYPE DF PUMP PVC. PIPE- FILL (,iOrrpM TV 4116 - TSAC4 !LOWAO <br /> `ENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ^c <br /> INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING <br /> rl DOMESTIC/PRIVATE IT GRAVEL PACK/SIZE_ TYPE OF CASING/STEEL/PVC DIA. OF WELL CASING ` <br /> PUBLIC/MUNICIPAL IT DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> am IRRIGATION/AG IT OTHER GRWT SEAL INSTALLED BY GRWT BRAND NAME , <br /> [T MONITORING FT GRWT SEAL PIMPED: E3 Yes ❑ NO CONCRETE PEDESTAL BY DRILLER: EI Yes IT No <br /> mPPNOX.DEPTH I t LOCKING CHESTER BOX/STOVE PIPE <br /> ]POSED CONSTRUCTIONIDRILUNO METHOD: MUD ROTARY_ AIR ROTARY_AUGER_CABLE_ DTHER_ <br /> I hereby certify that 1 have prepared this Application end that the--work be done in accordance with San Joaquin County Ordinances, <br /> ;tate Laws, and Rules and Regulations of the San Joaquin Canty. Home owner or licensed agent's signature certifies the following: 411 <br /> -tify that in the performance of the work for which this permit is issued, 1 shall not employ persons subject to WDRKMAN'S COMPENSATION <br /> as of California." Contractorfs hiring or subcontracting signature certifies the following: " 1 certify that in the performance <br /> 'EST <br /> work for which this permit is issued, 1 shall employ persons subject to"MAW'S COMPENSATION Law.of California.' THE APPLICANT <br /> VAST CALL 24 MO RS IY AO C DN•4LL_ UUIIED INS ECTIONS AT 12001"S 3423. Complete drawing at {offer area provided. 1114 <br /> -'Anel X /6/(/n/ PAYMENT <br /> _ rte-- -��-_� title P C('�,9t/'[t OR /JY <br /> I ttl9EN 1 <br /> PLOT PLAN (Draw to Sealed.,,$pTale�,aysYr'.M+to <br /> m� Names of streets or roads nearest to or hooding the prope rt s�-MCV CrEtI4 Location of house sewage disposal system or <br /> Outline of the property, aT dimx,. ab North di rettiE4r L' 6 1334 proposed expansion of sewage cusp f1 systems. <br /> Dimensioned outlines and Iota on of all existing and proposv�" 5 Location of wells wi Shin radius of i5D ft on <br /> structures, including cover reas such as patios, driv�pb)QAQLuIPJ CQUN Fy phe property or adjoining property. <br /> and walks. \ PUBLIC H[ LTHSE.RVICEb <br /> 1 ' F. ,IVISION <br /> A 111 11 1 <br /> DEPARTMENT USE ONLY \ 1 <br /> empplicatiOn Accepted By Date z- <br /> Grout Inspection By Data Pump Inspection By Date <br /> astruction Inspection BY Data/2 Comments: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED GNC CASH RECEI,EO BY GATE PFRMITISERVICE REQUEST NUMBER INVOICE <br /> �3 � o co. rrre L5 <br /> I <br />