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- APPLICATION FOR WELLIPUMP PERMIT -- <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERYI, <br /> ENVIRONMENTAL HEALTH DIVISION V <br /> P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201-388 <br /> (209) 488-3420 <br /> MON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete is Triplicate) <br /> Application is here by made to the San Joaquin County for a permit to construct and/or install the work described. This 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 Di/vision. <br /> Job Address/or APN# Isx7� L Iio City 1 Parcel Size/APN# J <br /> owner's Name L^� C'a t-e Address Phone # 1$erga <br /> Contractor Address /1:3bA tel!A[{(Yy) yet Lic# Phone #_9<-6-44y <br /> ",, �-�7-, a <br /> Sub Contractor 511 � f�iddress z[_A G' ±: L i c#592.6� Ph nes#29 3-2 <br /> TYPE OF WELL PUMP: )(NEW WELL [I REPLACEMENT WELL 0 MONITORING WELL # 0 OTHER 1 <br /> [I DESTRUCTION [] OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL # 0 SOIL BORING 6 <br /> [I INSTALLATION (I WELL SYSTEM REPAIR [I CROSS-CONNECT REPAIR VAPOR EXTRACTION WELL <br /> (TYPE OF PUMP) 0 New [I Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> [) INDUSTRIAL [3 OPEN BOTTOM DIA. OF WELL EXCAVATION LJ DIA. OF CONDUCTOR CASING <br /> 0 DOMESTIC/PRIVATE Il GRAVEL PACK/SIZE TYPE OF CASING/STEEL/ V DIA. OF WELL CASING <br /> 0 PUBLIC/MUNICIPAL [I DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> 0 IRRIGATION/AG 0 OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME ' <br /> MONITORING / GROUT SEAL PUMPED: 0 Yes 0 No CONCRETE PEDESTAL BY DRILLER: 0 Yes 0 No E <br /> APPROX.DEPTH - LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTRUCTIONIDRILLING 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 County Ordinances, <br /> State Laws, and Rules and Regulations of the San Joaquin County. Home 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 <br /> Laws of California." Contractor's hiring or sub-contracting signature certifies the following: w 1 certify that in the performance <br /> of the work for which this permit is issued, I shall employ persons subject to WORKMAN'S COMPENSATION Laws of California." THEAPPLICANT <br /> MUST CALL/24 HH?p UR N ADVANCE FOR AL REOUiRED INSPECTIONS AT{2091 488.3423. Canplete drawing at lower arre1a pprovjide�. <br /> Signed X �V Title t5F ('%)fl_b-(3 z -1- Date9/��� <br /> PLOT 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 f <br /> 2. Outline of the property, giving dimensions and North direction. proposed expansion of sewage dispose( 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 /> DZ <br /> r <br /> I T__ flu <br /> i DEPARTMENT USE ONLY <br /> Application Accepted BY Date ` S Area v l <br /> Grout Inspection By L Date Pump Inspection By Date <br /> Destruction Inspection By Date Comments: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKMCASH RECEIVED BY DATE PERMITJSERVICE REQUEST NUMBER INVOICE <br /> r <br />