Laserfiche WebLink
APPLICATION FOR WELLIPUMP PERMIT <br /> }} ° SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES � <br /> 3= ENVIRONMENTAL HEALTH DIVISION �■If'! <br /> P 0 BOX 389,445 N.SAN JOAQUIN ST.,STOCKTON,CA 95201.641''.ii:lar <br /> Rost 41118-3420 ' fi`r7 y A,.Tit <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 36 4j Jt, C I:(CamPl.0 r Tr�pikah] � z� p <br /> vidt <br /> ��jj,C s <br /> Application is here by made to the Sen Joaquin County for s permit to construct and/or install the work descr JET i application is <br /> .made in comp(fance with San Joaquin Canty Oevelopment Title, Chapter 9-1115.3 and the Standards of San Joaquin county.Public Health <br /> Services, Envircn;*Mtal Health Division.. <br /> If <br /> Job Address/or APMI_ � e�, IOP/ h __ City 4-dpl Parcel SI:e/APM* •5 - <br /> j` /i�IRQ•7 �El> '•� Address/rl3V ADAy492> A`, 4401. !l•- fO Phone 8 3Gff-.37- <br /> Owner's Rome <br /> If. <br /> /Contractor /.tJ•7// ���17✓/r Jil/�Tl/Atl&ess/1�O3 /Il./]��Y/CA � �, Lic# IAy(9ZZ? Phone 0 956'OUV <br /> Is - <br /> Sub Contractor Address Lic/ Phone M <br /> Ii <br /> TYPE OF YELL/PUMP: [] NEL WELL - [] REPLACEMENT WELL C1 FNYNITORING WELL f [7 OTHER <br /> F - [I DESTRUCTION [7 OUT-OF-SERVTCE WELL [] GEOPHYSICAL WELL 4 SOIL BORING Awkxvs-3 <br /> I [1 INSTALLATION (I WELL SYSTEM REPAIR C] CROSS-CONNECT REPAIR (I VAPOR EXTRACTION WELL N <br /> f: <br /> i1 TI New [I Repair N.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> A <br /> imiENDED use TYPE OF WELL CDNSTRUCTION SPECIFICATIOAR y <br /> 13, INDUSTRIAL (] OPEN BOTTOM DIA. OF WELL EXCAVATION 145' DTA. OF CONDUCTOR CASING /"0 <br /> it <br /> 11�DOMESTIC/PRIVATE 17 GRAVEL PACK/SIZE TYPE OF rASIAG/STEEL/PVC IVIR - DIA. OF WELL CASING <br /> 11'PUBLIC/M)RICIPAL 17 DRIVEN - DEPTH OF GROUT SEAL_ 55 __ SPECIFTCATtON , <br /> []liRRIGATION/AG 17 OTHER GROUT SEAL INSTALLED BY GROUT BRAND MANE i t <br /> AMONITOR(MG GROUT SEAL PUMPED: •0 Yes 'WINO CONCRETE PEDESTAL BY DRILLER: 0 Yes [7 No <br /> APPRUX.DEPTH LOCKING CHESTER BOX/STOVE PIPE � <br /> PR6POSE0 CONSTRUCTIDN[DAILLINO METHOD: MUD ROTARY AIR ROTARY_AUGER_CABLE_OTHER Cir i <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, <br /> State Laws, and Rutes and Regulations of the San Joaquin County. Norco owner or Licensed agentrs signature certifies the following: "I i <br /> certify that in the performence of the work for which this permit is issued, I shall not employ persons subject to WORKMAN'S COMPENSATION !} <br /> Laws of California.* Contractor's hiring or sub-contracting signature certifies the following: " 1 certify that in the performance <br /> of•the work for which this permit Is issued, 1 shalt employ persons subject to WORKMAN'S COMPENSATION Laws of Callfornia." THEAPPLICANT I <br /> MUST CALL 14 HO IN OYA FOR ALL REDO AED INSPECTIONS AT RO11 466.3427. Complete drawing a lower arae/provided. / <br /> !' Titla (EGT C7,7CoGr-� Date <br /> Signed X <br /> PLOT PLAN (Drew to Scale) Scale " to <br /> II streets or rands 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 system. <br /> 3. Dimensioned outlines and location of all existing and proposed 5. Location of wells within radius of 156 It. an <br /> _h structures, including covered areas such as patios, driveways, the property or adjoining property. <br /> and walks. <br /> l <br /> �k <br /> i <br /> �I <br /> �1 <br /> Jf <br /> f <br /> 1, <br /> dY <br /> DEPARTMENT UBE DMIY <br /> S} is <br /> Application Accepted By - - Date�..2T- Area <br /> Grout inspection 8y Date Pump Inspection By Date <br /> Destruction Inspection 8y Date cNownts: <br /> F!ACCDUNTINO ONLY: AID# FAC! <br /> .�{ PE CODES FEE INFO AMOUNT REMITTED CNECNIICASH RECEIVED BY DATE PERMITiSEAVICE REGIff"NUMBEN INVOICE <br /> 8 f23MAO Z.ZS O <br /> ;i <br />