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70 d, la101 <br /> APPLICATI0 N FOR WELLIPUMP PERMIT <br /> '--'SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIt4 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, TOCKTON, CA 95201.380 <br /> (209) 468.3420 <br /> NON-REFUUDABLE PERMIT EMPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Trblleate) <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 9-1115.5 and the Standards of San oaWin county Public Health <br /> Services, Environmental Health Division. <br /> Job Address/or APN#-4z2"eA4City Parcel Sire/APN# J5.6X-0/ <br /> Owner 0 s Name'/ Add`ress z / /• '^' ! Phone #209-94vo-e z <br /> ContractorATil�I�y� Address 32 fz lic#�� 5f�9 Phone #9.fO'lo 'r�Z�b <br /> Sub Contractor. /,5iQZ, �z;947C/�K' ��L1/�' Address�l�/� �iH�i�L.` _ Lie Phone <br /> TYPE OF WELL/PUMP-: EW WELL 11 REPLACEMENT WELL MONITORING WELL #A/Z/7o D OTHER <br /> (7 DESTRUCTION [I OUT-OF-SERVICE WELL /C3 _-GEOPHYSICAL WELL # E7 SOIL BORING <br /> INSTALLATION (I WELL SYSTEM REPAIR E7 CROSS-CONNECT REPAIR [I VAPOR EXTRACTION WELL # <br /> _ D New [) Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF TWELL CONSTRUCTION SPECIFICATIONS <br /> [I INDUSTRIAL C7 OPEN BOTTOM DIA. OF WELL EXCAVATION SNC ___ DIA. OF CONDu TOR CASING----- <br /> C) <br /> ASING C) DOMESTIC/PRIVATE V'GRAVEL PACK/$IZE�fi7- TYPE OF CASING/STEEL/PVC 1pyif DIA. OF WELL ASING <br /> C) PUBLIC/MUNICIPAL E7 DRIVEN DEPTH OF GROUT SEAL cJ T SPECIFICATION! se-,r 9� <br /> El IRRIGATION/AG [7 OTHER GROUT SEAL INSTALLED SY 04fg/G .� GROUT BRAND +C­ <br /> MONITORING <br /> MONITORING _ GROUT SEAL PUMPED: C7 Yes X-No CONCRETE PERE TAL BY DRILLER- es [) No <br /> APPROX.OEPTH 2O LOCKING CHESTER BOX/STOVE PIPE B'dX <br /> W <br /> PROPOSED CONSTRUCTIOUIDRILLING METHOD: MUD ROTARY,_ AIR ROTARY_ AUGER,L,,GABL.E_ OTHER_ O <br /> 1 hereby certify that [ 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 agents signatur4 certifies the following: 0, <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 subcontracting signature certifies the following: " I certify that in the performance <br /> of the work for which this permit is issued, I shall euploy persons subject to WORKMAN'S COMPENSATION Laws Cf California." THE APPLICAUT <br /> 13UST CALL 24 HOURS IN ADV HCE FOR ALL REQUIRED IEISPECTIO138 AT(205)488.3423. Complete drawing at lower area provided. .d 11.33 <br /> Title sem/ 4 /ug: �6it7" oaten/�3 <br /> Signed X , <br /> 4 <br /> PLOT PLAN (Draw to Scale) Scale• "o <br /> 1. Names of streets or roads 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 di"set systems. A <br /> 3. Dimensioned outlines and location of all existing and proposed S. Location of wells isithin radius of 150 ft. on <br /> structures, including covered areas such as patios, driveways, the property or adjoining property. <br /> and walks. <br /> LJ —..I—J— —L-L—— <br /> P <br /> y I � <br /> DEPARTMEUT USE ONLY <br /> Application Accepted By Date �✓ `" Area,— <br /> �` Date P inspection By. Date <br /> Grout inspection By _-- � Fx <br /> Destruction Inspection By Date _ Comments: /2�WiI <br /> ACCb it NTIHO ONLY: AID# - - F <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASN RECEI! D BY DATE PIRMITISERVICE REQUEsy T7UmR IUV010E <br />