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APPLICATION FOR WELLJPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SEXYIC <br /> ENVIRONMENTAL HEALTH OIVISI011 <br /> P O BOX IBB, 446 N.SAN JOAQUIN ST.STOCXTON,CA 96201aBs - <br /> yr =I 4884420 ! <br /> RO>EREFUMDABIE PERMIT"BE11 R FROM OATS ISSUED � ° <br /> Appi(eation is here WwepifteAm irMfil4aY <br /> by soda to the San JargJin Canty for •permit to constrUet and/or install the wort deserfbad. This appltGation Is <br />{ ; made In Compliama with San Joaquin County oeveiepzeeent'Titto, Chapter 9-1115.3 and the Stands <br /> Services, E,nvirormental.,He/alth Divi�sioon. /_ r'Ci of Sen Joaquin Canty Public Health <br /> Job Address/er APMN Ctey ��1�/'+t- dzti 4 <br /> / Parcel S12e/APU <br /> Owner's Name /I U4 63 1'-WeLS Address EO, 1?11)<W 71V/26 phone - <br /> Contractor lr a1FOh Address ?1/ ✓�4 <br /> Lich Phone ,N <br /> '� <br /> Sub Contractor elfp Address�O, p - / ! Gt�iT�C. LieN S�2/ <br /> TYPE OF BELL/PLMP�y Q NEW WELL Q REPLACEMENT WELL �:OTHER /Syef'(y�cr/fe_�, <br />[ Q MONITORING WELL N <br /> Q DESTRUCTION Q OUT-01-SERVICE YELL 0 GEOPMTSICAL WELL N SOIL amtmc <br /> Q INSTALLATION ly WELL SYSTEM REPAIR p CROSS-CONNECT REPAIR Q VAPOR EXTRACTION WELL N <br /> LI Now Q Repair e.P. DEPTH PIMP SET FT. FIRST WATER LEVEL <br /> STYPE DF PIMP) ` <br /> INTENDED USE TYPE DF WEII CONSTRUCTION SfQFICATION! <br /> Q INDUSTRIAL U OPEN BOTTOM DIA. OF YELL EXCAVATION DIA. OF CONDUCTOR CASING <br /> Q DOMESTIC/PRIVATE Q GRAVEL PAC1(/SIZe TYPE OF CASING/STEELJPVC OIA. OF WELL CASING, <br /> Q PURLICJMUMICIPAL Q DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> {] [RRi CATION/AG Q OTHER GROIiT SEAL INSTALLED BY GROUP DRAW NAME <br /> r MONITORING GROUT SEAL PIMPED: Q;Yes Q No CONCRETE PEDESTAL BY DRILLER: Q Tem I) No <br /> APFUL DEPTH ;20 �e- LOCKING CHESTER Sax/STOVE PIPE y <br /> PROPOSED CONSTRUCTIONIORMUNG METHOD: LLA ROTARY_AIR ROTART�_AUGER_CABLE„_OTHER, <br /> I hereby certify that I have prepared tail applicacien and that the wort,witl be done in accordance with San Joaquin County Ordirmwes, <br /> State Lara, and Rules and Regulations of the San Joaquin County. Home owner or licensed agent's signature certifies the following: 11 <br /> certify that in the performance of the work for which this permit is issued, I shall notflay persons subject to WRKMAN�S COMPENSATION <br /> Laws of California." Con[raCtar's hiring or sub-contracting signature certifiea the foltowing: - 1 certify chat in the performance <br /> of the work for which this permit is isased, I shawl employ persons subject to WIORKKUIS COMPENSATION Laws of California.- THEAPF1UCANT <br /> MUST CALL 24 HOURS IN ADVANCE feat ALL UJIBI 3 ins ECTION2 AT Cop 4W3423. -Complete drawing at lower area provided. <br /> rs <br /> Signed x .�+ 2VTitle IF-20"'c" J Dace pl�3i 9' <br /> 4 <br /> PLOT PLAN (Draw to Scale) Seale—, to <br /> 1. Napes of streets or roads nearest to or bounding the property. 4. Location of home sewage disposal systam or <br /> 2. outline of the property, giving dimensions and North direction. proposed expermlon of sewage,disposal systosm. <br /> 3. Dimensioned outlines and location of all existing and proposed 5. Location of wells within radius of 150 ft. an <br /> structures, Including covered areas such as patios, driveways, the property or adjoining property. 5 <br /> and walk a. <br /> JlJ �J °G js <br /> I <br /> i <br /> f � <br /> r I <br /> I <br /> .I <br /> H. i <br /> Va�i� 0���(.,a ✓ 4�GC�tpt DEPAQM13IT0SEul¢Y_ I,'3f V���'`-� ��I"�LJ` I'►l'+'l� <br /> Application Accepted ey Da[e��� 1 U��_ A"a <br /> Grout Inspection By Data` Pulp Inspection ay Data <br /> Destruction Inspection ay Data' - Comments: <br /> ACCOUNTING DMLY: AIDN FACE ,I <br /> PE CODER FEE LNFD AMOUNT XBOTTED GKIWICASM RECEIVED BY .0A It PERMIT1fEMCE REDDEST NUMBER INVOICE - <br /> 542 ar. V oi �3 <br /> i <br /> f <br />