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• APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES • LIU /�LO� <br /> ENVIRONMENTAL HEALTH DIVISION �q <br /> P 0 BOX 388,446 N.SAN JOAQUIN ST., STOCKTON,CA 95201-38B <br /> (209)4683420 4 17 <br /> �, �9 <br /> NOR REFUNDABLE PERMIT <br /> GmpMbEXPIRES <br /> TtyliuUl FROM GATE ISSUED /'F?�,ypFryT 9q <br /> Application is here by made to the San Joaquin County for a permit to construct and/or install the work describaEFF/11 li{cetlan is <br /> meet in compliance with Sen Joaquin Canty Development Title, Chapter 9-1115.3 and the Standards of San Joaquin C�k/c Health <br /> Services, Environmental Health Division. �1 <br /> Job Address/or APNN HIF .S/Um•,l il_ <br /> Ccity 6rk C,4' ,1 parcel Site/APN# <br /> Oner's Name uS J:, m taI Address P111f 5A•.✓ .,2,4 Phone N <br /> Contractor Ard.k L USa it RSSOG• Address/02'S— 611 <br /> Lie# Phone N7ll6 H`�Q� <br /> Sub Contractor Address Lich Phew#yl!"'PiS�—H19S <br /> TYPE OF WELL/PINP: 1111NEW WELL [IREPLACEMENT WELL PC MONITORING WELL #AV-1 p OTHER <br /> J1.,DESTRUCTION O OUT-OF-SERVICE WELL H GEOPHYSICAL WELL # DSOIL BORING <br /> D,INSTALLATION IT WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR 11 VAPOR EXTRACTION WELL N <br /> 11 New 11 Repair N.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ,oC� <br /> D INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING <br /> D DOIESTIC/PRIVATE [1 GRAVEL PACK/SIZE_ TYPE OF CASING/STEEL/PVC DIA. OF WELL CASING <br /> H PUBLIC/MUNICIPAL IT DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> ❑ IRRIGATION/AG [1 OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> Sc MONITORING / GROUT SEAL PLWPED: )(Yes [1 No CONCRETE PEDESTAL BY DRILLER: D Yea D No <br /> APPROX.DEPTH 90 LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CON STRUCTIO MIDRILLING METHOD: MM ROTARY_AIR ROTARY_AUGER CABLE_OTHER_ "I♦O_ <br /> 1 hereby cart Iy that 1 have prepared this application and that the work will be time in accordance with San Joaquin County Ord!names, <br /> State Laws, and Rules and Regulations of the San Joaquin County. Home owner or licensed agent's signature certifies the following: 461 \ <br /> certify that in the performance of the work for Mich this permit is issued, 1 shall nwt employ persona subject to WORKMAMOS COMPENSATIOII\-Q <br /> Laws of California." Contractor's hiring or sub-contracting signature certifies the following: e 1 certify that in the performance <br /> of the work for which this permit Is issued, 1 shalt employ persons subject to WORKNAN'S COMPENSATION Laws of California." TWE APPLICANT <br /> MUST CALL 24 HOURS IN ADVANCE FOR ALL REDWAEO INSPECTIONS AT 1209)46113423. Complete drawing at lower area provided. <br /> Signed A Lr/ Title_r Il- S['i to Lr 4£- Dat <br /> N / e'" <br /> PLOT PLAN (Draw to Sole) Seats to <br /> 1. Names of streets or roads nearest to or bounding the property. 4. Location of hate sewage disposal system or <br /> 2. outline of the property, giving dimensi me and North direction. proposed expans l on of sewage disposal systema. <br /> 3. Dimensioned outlines and location of all existing and proposed 5. Location of wells within radius of 150 ft. on <br /> struc turas, Including covered areae such as patios, driveways, the property or adjoining property. <br /> and walks. <br /> W <br /> 1Y1W 9 II , <br /> U Sn <br /> e� Y <br /> fzu <br /> er <br /> Id- <br /> A <br /> DEPARTMENT USE ONLY p <br /> AppLication Accepted By Date ` Area <br /> Grout Inspection By COMPLETED pulp Inspection By * Date` <br /> Destruction Inspection By 9�� gs Laments: WD -e. <br /> ACCOUNTING ONLY: AIDN I FACN Y <br /> PE CODES FEE INFO AMOUNT REMITTED GHECKfICASX REGEIVP BY DATE PERNITISERVICE REQUEST NUMBER INVOICE <br />