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APPLICATION FOR WELLIPUMP PERMIT / ..�D <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 00/va/'/�Av <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388,445 N.SAN JOAQUIN ST.,STOCKTON,CA 95201388 <br /> (209)4683420 <br /> NOM REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> Naalau Y MPRestal <br /> Application is here by rade to the San Joaquin Canty for a permit to construct and/or install the work described. This application is <br /> ade in capl lance with Gan Jo"In County Development Title, Chapter 9-1115.3 and the Stardards of Gan Joaquin Canty Public Health <br /> Services, EnVirome,tal Health Divi s/i (,//�J <br /> Jab Addrsss/or APR# �j d6 !� G`l� F� (F City Z"/ parcel Six./APNB <br /> � one <br /> ph <br /> Oror'e Nap �( <br /> Address sea <br /> Contractors r '^a Q n �/L�✓ Address L UseMone a- <br /> GW Cmtractor Address Lica Mone 4 <br /> TYPE OF WELL/PUMP: L1 NEN WELL LI REPLACEMENT WELL O MONITORING WELL f 0 OTHER <br /> [1 DESTRUCTION U OMIT-DF-SERVICE WELL [I GEOPHYSICAL WELL B O SOIL BORING <br /> D INSTALLATION D WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL N_ <br /> D Mew )LIt"Ir H.P. ( DEPTH PUMP SET SM FIRST WATER LEVEL`L_ <br /> (TYPE 0F PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICA11015 <br /> INDUSTRIAL [I OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF COM)UCTOR <br /> CASING <br /> 'IKDOMESTIC/PRIVATE U GRAVEL PACK/SIZE- TYPE OF CAGING/STEEL/PV[ DIA. OF WELL CASING <br /> D PUBLIC/MUNICIPAL O DRIVEN DEPTH OF GROAT SEAL SPECIFICATION <br /> D IRRIGATION/AG U OTHER GROUT SEAL INSTALLED BY GROUT GRAND NAME <br /> IT MONITORING / GROUT SEAL PIMPED: El Yes D No CONCRETE PEDESTAL BY DRILLER: D Yes [I No <br /> APPRDIL BPPTH S LOCKING CHESTER SOX/STOVE PIPE <br /> PROPOSED CONSTRUCTIOMDRULING METHOD: NLD ROTARY_AIR ROTARY_AUGER_CABLE_OTHER15,_ <br /> 1 her certify that 1 have prepared this application and that the work will be done in ucortlance with San Joaquin Canty Ordinances, Fr <br /> Gtate Lew, and Rules and Regulations of the San Joaquin Cana ane <br /> County. Hor or licensed!egmt's signature certifies the following: 1-1 <br /> certify that in the perforarce of the work for which this Pamit,is issued, I shall not asploy Persons subject to WOIEHAN'S COMPENSATION S, <br /> Lew of California." Contractor', hiring or subcontracting signature certifies the following: " i certify that in the perforame <br /> of the work for which this permit is issued, L shall esploy persons SubJact to WORpMN'S COUENSATION Laws of California." TNEAPPLUNIT -� <br /> MUST CALL 24 HOURS IM ADVANCE FOR ALL REQUIRED INSPECTIONS AT J2011 ABB->•S1. Caglete drawing at Lover area provided. <br /> Signed Title /i!lC Dete <br /> PLOT PLAN (Draw to Scale) Sole_" [o <br /> I. Nass of struts or roads nearest to or b,udim the Property- A. Loot(w of hone sewage disposal systa or <br /> 2. Outlies of the property, giving dimension end North direction. proposed expansion of sewage disposal systea. <br /> 3. DisvYtoned outlines and locadm of all existing and propoasd 5. Location of wells Within radius of 150 ft. on <br /> structures, including covered areas such as patio, driveways, the property or adjoining property. <br /> and wika. <br /> "u <br /> as <br /> 0 2 7 <br /> ---------------- <br /> E U N <br /> DEPARTMENT USE ONLY <br /> Application Accepted BY Dete Areaeo-f <br /> Gran Inspection BY Data Pt" Impaction By Data <br /> Destruction Inspection By Date CaI <br /> ACCOUNTING ONLY: AID# FAC, <br /> PE CODES FEE INFO AMOUNT REMITTEO CHIC CASH RECEIVED BY DATE PERMITISERYICE REQUEST NUMBER INVOICE <br /> S a lI 7 d <br />