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APPLICATION F;IR WII�LIPUMP PERMIT <br /> SAN JOAl2UIN COUNJY PU LIC HEALTH SERVICES <br /> ENVIRONMEN�%L H LTH DIVISION <br /> P 0 BOX 388, 446 N. SAN JO-J41.11N T., STOCKTON, CA 96201-388 <br /> (209 468- 20 <br /> NDN-REFUNDABLE PERMIT E'PIRES I YEAR FROM DATE ISSUED <br /> (C6mpIaV, in Trrl Beate) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTR XT ANDS R INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPUANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN Jt' N COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION.PARCEL SIZE/APNX ✓J <br /> JOB ADORESS,'OR APNN 4SC�h�I'�r S1/�-Y�' �t/'iT` � � O <br /> / L / CITY ��Y�•t/ C( �� <br /> OWNER'S NAME_`7L j��i, ��J�r—�/ ADDRESS 16t7 UCY z6l Y✓�Q��G/J.G�,� ��3PHONE N <br /> CONTRACTOR /p;•(/ �i q/b £/�5 L <br /> ' <br /> ADDRESS /�3SV.�L iS UCN r�G[�SC'p pF{ONE# <br /> SUB CONTRACTOR —�— <br /> ADDRESS UCN PHONE# <br /> TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL N ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J <br /> (TYPE OF PUMP) <br /> 1-1New1:1 Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL N VVV ��`SOIL BORING 42g, t.-r�/1 B <br /> ❑DESTRUCTION: by•L E� <br /> INTENDED UbE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ❑ <br /> A <br /> INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION Z (•/L li DIA.OF CONDUCTOR CASING <br /> ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC ^/ DIA.OF WELL CASING O <br /> O <br /> PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> B <br /> IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> E <br /> MONrrOPJNG / GROUT SEAL PUMPED: ❑Yea o CONCRETE PEDESTAL BY DRILLFR:Ely. ❑No S <br /> APPROX.DEPTH (� �� LOCKING CHESTER BOX/STOVE PIPE <br /> S <br /> PROPOSED CONSTRUCTION/DRIWNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER J/Lu-f_LT <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA." CANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS6&3 <br /> // AT(2001 4423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> slanee x Tit I /cc�� c=� ��G_octil.JT Data <br /> PLOT PLAN(Draw to Scalel Scale "to <br /> 1. NA SOF STREETS OR ROADS NE ST TO OR BOUNDING THE PROPERTY. <br /> -v_ T <br /> . I L�A,61F%F <br /> "Lk <br /> =A41 <br /> w: <br /> Ftcc..Et %vi= <br /> A,-'-00S wz4.;.fix <br /> DEPARTMENT USE ONLY <br /> Application Accepted By ��AAAr��� Date Area <br /> Grout Impaction By Date P—P Inspection By Date <br /> Deatrmtion lmpe ion By /�� Date/ <br /> Comments: L,J rn�/1/��f' t..,, � (A L1rL �iV I Z <br /> ACCOUNTING ONLY: O AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DAT PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> S D <br /> 0 03 <br />