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APPLICATION FOR INELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388,445 N.SAN JOAQUIN ST. STOCKTON,CA 96201388 <br /> RETS)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FARM DATE ISSUED <br /> lCawbw Is TnpRsaM) <br /> Application is here by sees to the San J°sq+in Canty for a permit to construct srd/or install the work dewribed. This application 11 <br /> wee in capliame with San Joatpin Canty Developasnt Title, Chapter 9-1115.3 and the Standards of Sam Joa udn Cally Public Smith <br /> services, Emirac 1GL Health Di Vii Sfar. <br /> Jab AddN:/ <br /> res./or AP3 hV? W.I&KP. city Po-d�? C� Parcet site/~ <br /> Ower's Naas Address,& 5/S t=•.Ufa j20�. ���� Phone#3LLI2i z <br /> Contractor ACS....('gia a Y_++Q /vZ'. L+N/61373 ph.DEfG6^SG OMP' <br /> sub Contractor — Address L+CS Ph"0 <br /> TYPE OF WELL/PCW: D NEN WELL [1 REPLACEMENT WELL I] MONITORING WELL R II OTHER <br /> D DESTRUCTION D OUT-OFSERVICE WELL U GEOPHYSICAL WELL N D SOIL BORING <br /> W INSTALLATION D WELL SYSTEM REPAIR D CROSS-COMNECT REPAIR D VAPON EXTRACTIONWELL a111-11, _ <br /> 11 New [R Repir X.P. DEPTH PUMP SET SO FT. FIRST NATER LErc'( <br /> I_ <br /> (TYPE OF PUP) <br /> INTENDED USE TYPE Of WELL CONSTRUCTION SPECIFICATIONS <br /> [] INDUSTRIAL i] WEN BOTTOM DIA. Of WELL EXCAVATION OIA. OF COMIX:TCR CASING <br /> — <br /> [I DOMESTIC/PRIVATE I] GRAVEL PAU/SIZE_ TYPE OF CASING/STEEL/PVC DIA. OF WELL USING <br /> (1 PUBLIC/Mr ICIPAL [] DRIVEN DEPTH OF GROUT SEAL SPECIFIUTION <br /> IRRICATIDN/AG D OTHER GROUT SEAL INSTALLED BT GROUT BRAND NNIS <br /> [I HON ITORING GRWT SEAL PUMPED: D Yea D No CONCRETE PEDESTAL BY GRILLER: 0 Yea p NR <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE .� <br /> PROPOSED CONSTRUCTIONIDNLUNO METHOD: MID ROTARY_AIR ROTARY_AIDER_CABLE_OTNER_ <br /> 1 hereby certify U.N. 1 haw'..Oral Ola&N,Li catim and that the work wi1L M dote in sccordarce with S.Joaquin Canty Ordinances, <br /> State Law, all Rules end Ra9uLetirM of the San Joaquin Canty w. n <br /> Hone or or licese agent's signature certifies the following: "1 <br /> certify that +n the prformrpe <br /> ce Of the work for which this permit is issued, i shalt mt awpLoy persona subject to USEQUEN'S COMPENSATION <br /> Laws of Eli fornia.n Contractor's hiring or sub-cmtracting signature Certifies the followim: " I Certify that I. the performance I� <br /> of the wort for which this prwit is issued, i shalt aaplgy Arsons Object to WORKMAN'S COMPENSATION Law of California.^ THEAPPLICANT m <br /> MUST CALL U NBOSO■ADVANCE <br /> �FOR <br /> /ALL ENDORSED MaPECTIONS AT ROB)NL3U3. Caiplete drewinp+at_Lower area provided. <br /> Title H/5 Dete +'a <br /> sirstl x F <br /> PLOT PLAN (Draw to Scale) Scale------• to <br /> 1. Maws of street. or roads neRrwt to or bovding the Property. 4. Location of haus Dew a di di.t ."t.or . <br /> 2. OMliw of the property, Divlry di Remims rd North direction. p°P°a MBM,,A <br /> jch5. Location of wells within radius of 150 ft. on <br /> 3. Dt.t.r.ed outline ell Lecs<Im of all e.i pati. and proposed the property r adjoining Property <br /> c[ructurec, ircltdins eaOrad crew such ea pain, driveaayc, P open r° <br /> all walks. <br /> Aid �'n 5.,vi <br /> fi- <br /> DEPARTMENT USE ONLY [1� <br /> D e z. Cl 5 Area�jsy- <br /> Aplica[im A¢epted By <br /> Grout Inspection By IJ Date Pup 11 tion By OSAfS <br /> Destruction Inapction BY Data C—ts: <br /> ACCOUNTING ONLY: AIDS FACO <br /> PE CODES TEEMED AMOUNT REMITTED NEC NCASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br />