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m,O'd -11+101 <br /> APPLIdkiON FOR WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION til/! <br /> P 0 BOX 388,446 N.SAN JOAQUIN ST,STOCKTON,CA 96201.188 <br /> (209)488.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete M TtlpOeab) <br /> Application is bore by made to the San Joaquin County for s permit to construct and/or fnststl the work de¢¢eri6ed. This application is <br /> made in compliance with San Joaquin Canty Development Title, Chapter 9-1115.3 and the Standards of San .loequin County Public Health <br /> Services, Elnvirormentat Health Division. <br /> Job Address/or APNN Z/30 Gr,L�3�' Gr�i/-siyGroN 57- City G7VAI Parcel Eize/APNN <br /> Zo - 4G-Oz4ro <br /> Owner's Name PFj2T OF ' C,1�72Ji✓ Address Phone# <br /> ,,,� �GQ 9S 6v0 <br /> contractor F�Y�/k n�lWi✓�� Z7%/(!? Address— <br /> Address3g29 4e/`E Lich I Phone <br /> I <br /> Sub ContraetonS'/E.8?9—�9Ci/'!C 6Z Address 4 w/N /V Lfc#C66 //3 Phone t'4/ <br /> 6Z PevnoO i 6 <br /> TYPE OF WELL/Pu[lpi )MEW WELL O REPLACEMENT WELL MONITORING WELL N _ ❑ OT ER <br /> O DESTRUCTION [I OUT-OF-SERVICE WELL C1 GEOPHYSICAL WELL N O SCIL BORING <br /> [I INSTALLATION U WELL SYSTEM REPAIR O CROSS-CONNECT REPAIR [1 VAPOR EXTRACTION WELL <br /> I1 New 11 Repair H.P. DEPTH PUMP SET FT. FIRST WAVER LEVEL <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> [I INDUSTRIAL [] OPEN BOTTOM DIA. OF WELL EXCAVATION - —1AIC1/ DIA. OF CONOU TOR CASING <br /> O DOMESTIC/PRIVATE xGRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC_ ,LLC DIA. OF WELL Si NO 'Z--/.v Ch/ <br /> O PUBLIC/MUNICIPAL i) DRIVEN DEPTH of GROUT SEAL,O Z"�B�' SPECIFiCATIONL S�efi�q� /ted/ <br /> O IRRIGATION/AG CI OTHER GROUT SEAL INSTALLED BY ZEye/K GROUT BRAND N <br /> *MONITORING GROUT SEAL PUMPED:XYes [I He CONCRETE PEDESTAL BY DRILLER-XYes 11 No <br /> APPROX.DEPTH Z.O >'eET LOCKING CHESTER BOX/STOVE PIPE Si <br /> PROPOSED CONITRUCTIONIONHLLING METHOD1 NUD ROTARY_AIR ROTARY_AUOIR_)(_CAPLR_0111FR_ <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with So m Joaquin Canty Ordinances, Iy <br /> State Laws, and Rules and Regulations of the San Joaqufn Comty. Nome owner or licensed agent's Signatur certifies the.foltowin9t "I V <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- " I certify that in the performance <br /> of the work for which this permit is issutd, I shall employ persons subject to WORKMAN'S COMPENSATION Laws c f California." THE APPLICANT t� <br /> MUST CALL Z4 HOURS IN ADVANCE FOR ALL REOUIREO INSPECTIONS AT(209)4162422. Complete drawing at lower area p ovided. -71MI \C\ <br /> Signed X <br /> titleSes.�[/iO.P <br /> PLOT PLAN (Draw to SCSI*) scat& " to <br /> 1. Names of streets or roads nearest to or bounding the property. I.. Location of house irwage disposal system or <br /> 2. Outline of the propertye giving dimensions and North direction. proposed expansion of sewage disposal systems. <br /> 3. Dimensioned outlines and location of ell existing and proposed S. Location of wells tithin radius of 150 ft. on <br /> structures, including covered areas such as patios, driveways, the property or ad oining property. <br /> and walks. SES '177 iyliyP�S' �Fi / Z 3 <br /> DEPARTMENT USE ONLY �j <br /> Application Accepted Sy Date ! Ares <br /> Grout Inspection By Date Pump Inspection BY Date <br /> Destruction Inspection byDate Coneenta: <br /> r!� <br /> ACCOUNTING ONLY: AID# FACN L <br /> PE CODES FEE INFO AMOUNT REMITTED CRECKSICASH RECEIVED 9Y RATE PERMITIEERVICE REDO T NUMOE CE L <br /> 240 F`/ S! 7474 X00 d <br />