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APPLICATION FUR VVEIIIPUMP PERMIT <br /> gft SAN JOADUIN COUNTY PUBLIC HEALTH SERVICES • /� '��"�°" <br /> VF ENVIRONMENTAL HEALTH DIVISION , <br /> P 0 BOX 388,446 N.SAN JOAOUIN ST., STOCKTON,CA 86201308 j(// <br /> 12091 4883420 <br /> MON REFUNDABIE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED fryVl•'V <br /> ICAHPIFM M Triplicate) <br /> Application is here by made to the San Joaquin County for a permit to construct and/or install the work describMS.%ihis�application is <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. nn !! c' <br /> Job Address/or APN# lHyV Sl.a L✓ rt;tl City S'/tL/-fG'T Parcel Size/APN# <br /> owner's Nene /./.S, f/�>fn ria f Address/'/yf! 5'k Phone #l0V <br /> Contractor 11,11 41, le flSnn &S-C- Address/e 1Lc C �. ic# Phone #%/(-.�(z/-(�`��j <br /> Sub Contractor mil� Address&&o62,2 Sj Lry4%L a Phone#q/Gm-♦tS1'r/S57y <br /> TYPE OF WELL/PUMP: [I NEW WELL ❑ REPLACEMENT WELL IWMONITORING WELL M MI✓-3 ❑ OTHER <br /> DESTRUCTION ❑ OUT-OF-SERVICE WELL 11 GEOPHYSICAL WELL # 11 SOIL BORING <br /> [1 INSTALLATION [1 WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL # \ <br /> [1 New I7 Repair N.P. DEPTH PIMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WEIL CONSTRUCTION SPECIFICATIONS <br /> I1 INDUSTRIAL I1 OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING <br /> ❑ DOMESTIC/PRIVATE ❑ GRAVEL PACK/SIZE_ TYPE OF CASING/STEEL/PV[ DIA. OF WELL CASING <br /> H PUBLIC/MUNICIPAL IT DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> a❑ IRRIGATION/AG [I OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> ,/� <br /> p(MONIIORING / GROUT SEAL PUMPED: )j Yes ❑ No CONCRETE PEDESTAL BY DRILLER: D Yes ❑ NO <br /> APPROX.DEPTH 9O LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTRUCTIONIORILLINO METHOD: MUD ROTARY_AIR ROTARY_AUGER CABLE_OTHER_ <br /> 1 hereby s, and <br /> that 1 have prepared o to application and that the work will r done ie accordance with $an Joaquin County Ordinance"I <br /> Beate Lets, and Rules and Regulance of the <br /> of the Sen Joaquin County. Home owner or licensed agent's signature certifies the tCOMPENSAT ON N <br /> certify that in the performance of the work for which this permit n issued, I shell not employ persons subject to WORKMAN'S COMPENSATION <br /> Laws a Cal if orniach Cont permit <br /> hiring or cubtl employ pe signature certifies the followings N 1 certify that in the performance <br /> of the work for which this permit le issued, 1 shell employ persons subject to WORKMAN'S COMPENSATION Laws of California." THEAPPLICANT <br /> MUST CALL 24 HOURS IN ADVANCE FOR All REOUIREO INSPECTIONS AT(706)/RI Complete drawing at lower area provided. <br /> Signed X L Title ET✓ .Sin or,/'S!L Date <br /> PLOT PLAN (Draw to Scale) Scala--Z—.. to�.UO <br /> 1. Names of streets or roads nearest to or bounding the property. 4. Location of house sewage disposal ayctan or <br /> 2. Wiling of the property, giving dimensions and North direction. proposed expansion of sewage disposal systems. <br /> 3. Dimensloned outlines and location of all existing and proposed S. 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 walk.. <br /> 3f / <br /> 7 7T— <br /> N5. ' <br /> f / <br /> h <br /> L <br /> DEPARTMENT USE ONLY <br /> Application Accepted By_ Date AreaId <br /> Grout Inspection By $�OMPLVCZD Pup Inspection By <br /> Destruction Inspection By ZS-9 5- Comen[s: Dy <br /> ACCOUNTING ONLY; AID# FAC# t(/�'( <br /> PE CODES FEE INFO AMOUNT REMITTED CHECN#ICASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> 240-2- W D 3 2 7-uv- <br />