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APPLICATIUM rUH WLLL1PUMP PI:IMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 381, 446 N. SAN JOAQUIN ST., STOCKTON, CA 86201-398 <br /> (201) 468-3420 <br /> NON-REWNOABLE PSWT EXPIRES 1 YEAR FROM DATE ISSUED <br /> gempMta le 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/th. Standards of Sen Joaquin County Public Health <br /> Services, Environmental Health Division. <br /> Job Address/or APN! City Parcel Size/APNY <br /> r� n <br /> Owner's Name Address 7 / Phone # <br /> Contractor Address Lic#12 2-J 9D Phone <br /> Sub Contractor Address Lic# Phone 0 <br /> TYPE OF WELL/PUMP: 0 NEW WELL 0 REPLACEMENT WELL ❑ MONITORING WELL N [] OTHER <br /> [] DESTRUCTION El OUT-OF-SERVICE WELL [] GEOPHYSICAL WELL 0 [] SOIL BORING <br /> INSTALLATION ❑ WELL SYEM REPAIR [] CROSS-CONNECT REPAIR 0VAPOR EXTRACTION WELL <br /> Mew O Repair H.P. / DEPTH PUMP SET / -7'0 FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> INTENDEO USE TYPE OF WW CONSTRUCTION SPECIFICATIONS <br /> [] INDUSTRIAL [] OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING <br /> [] DOMESTIC/PRIVATE [] GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA. OF WELL CASING <br /> [] PUBLIC/MUNICIPAL [] DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> ❑ IRRIGATION/AG ❑ OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> [I MONITORING GROUT SEAL PUMPED: [] Yea I) No CONCRETE PEDESTAL BY DRILLER: [] Yes 0 No <br /> APPROX.DEPTH LOCKING CHESTER Bax/STOVE PIPE <br /> PROPOSED CONSTRUCTIONIOAILLING METHOD: MUD ROTARY_ AIR ROTARY_ AUGER_ CABLE_ OTHER_ <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with Sen Joaquin County Ordinances, <br /> State Laws, and Rules and Regulations of the San Joaquin County. Now 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, 1 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 issued, 1 shall employ persons subject to WORKMAN'S COMPENSATION Laws of California." THE APPLICANT <br /> MUST CALL 24 HOURS 1VANCE FOR ALL REO RED INSPECTIONS AT(208)488.3423. Complete drawing at lowerareaprovided. / <br /> Signed X Title /���$i Date`s <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 <br /> 2. Outline of the property, giving dimensions end North direction. proposed expansion of sewage disposal 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 prrty. <br /> and walks. 7 <br /> 4 <br /> 6SIN 11 <br /> � 4 <br /> 4l.t3�t r4� �^ �p L •F,�j �l�Ii <br /> +L <br /> i� <br />