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- APPLICATION FOR WELL(PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388,446 N.SAN 209)48N ST„ STOCKTON,CA 96201-368 <br /> (2D9)4883420 <br /> MON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED F„ <br /> (Complete M Triplicate) <br /> Application is here by made to the San Joaquin County for a permit to construct end/or install the work described. This application.[" <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. F11A.�11j1rr ,^�11 / n <br /> Job Address/or APNN W W qC <br /> ty a Parcel Size//�A/P�N# 7� <br /> PO <br /> Owner's Nam5 ?o e <br /> e rasa Q� r7 �7 <br /> Contractor 2AAddressh4v LicX_ Irl Phone +Y !" <br /> Sub Contractor fEws <br /> Address Lich Phone# <br /> TYPE OF WELL PUMP: FT�OWELL EPLACEMENT WELL I) MONITORING YELL X [I OTHER <br /> TRUCTION [) OUT-OF-SERVICE WELL (IGEOPHYSICAL WELL N [ISOIL BORING <br /> [) INSTALLATION 11 WELL SYSTEM REPAIR LI CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL N <br /> CI New [I Repair H.P. DEPTH PUMP SET FIRST WATER LEVEL <br /> (TYPE OF PUMP) /��/�� �1 / / F �.i�.��� L�jjB�O7-- <br /> INTENDED USE TYPE OF WELL CONSTRUCTIONS ECIFICATIOMS � ,� V "�`tC. <br /> _ <br /> [I INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WELL EXCAVATIONy DIA. OF CONDUCTOR'CASING'. <br /> [) DOMESTIC/PRIVATE ,GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC / DIA. OF WELL CASING <br /> 111116BLIC/MUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL / SPECIFICATION <br /> [) IRRIGATION/AG [) OTHER GROUT SEAL INSTALLED BY J GROUT BRAND NAME <br /> ❑ MONITORING GROUT SEAL PUMPED: V Yes [I No CONCRETE PEDESTAL BY DRILLER: [) Yes {�No <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE <br /> '` <br /> PROPOSED COMSTRUCT)OMID All LING METHOD: MUD ROTARY_AIR ROTARY_AUGER_CABLE_ OTHER_ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin CountyOrdinances <br /> Nome , <br /> State Laws, and Rules and Regulations of the San Joaquin County. Noe 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 T <br /> Laws of California-" Contrector's hiring or subcontracting signature certifies the following: 14I certify that in the performance V <br /> of the work for which this permit is issued, I shall employ persons subject to WORKMAN'S COMPENSATION Laws of California." THEAPPLICAMT <br /> MUST CALL 24 HO DVANCE F R A REQUIRED INSPECTIONS AT(209)4a2 3427. Complete drawing at er area provided. <br /> E <br /> Signed X Title .C/„ Date�'� <br /> t - <br /> PL 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 /> 11 Ne <br /> I <br /> �- <br /> HEA s FM ES <br /> Ll —111112511L&—IQTA� FI EAT ISI N— - - <br /> DEPARTMENT USE ONLY (�y- <br /> Date f Area/ <br /> Application Accepted <br /> Grout Inspection By <br /> LDate CD Pump Inspection By Date <br /> D s tion s ctiAn By Y r ` 1— ' —` Date Comments: Q� <br /> A MG 4NtY: AID# FAC# i!'.�.oa'1J' �iC,G'CC� <br /> PE;CODES FEEINFO AMOUNT REMITTED CHECK ASH RECEIVED BY DATE PERMITISERViCE NEOUEST NUMBEA INVOICE <br /> q32q 6-2 G`faalo <br /> DCS <br />