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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SER :S <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201.388 <br /> (209) 468.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in 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 the standards of San Joaquin County Public Health <br /> Services, Environmental Health Division✓.�I /y <br /> Job Address/or APN# 04 W• i/L2 .r-ry City Parcel 'I%APNI#733—L52m.- �3 <br /> � �� F-GC1 ALL-/ Address �J <br /> Owner's Name ^ ��'' �""��'' '' DS Phone #57-Y Oo797 <br /> Contractor �i �Z�UI,PL1V9 At(dress C 7' — Phone # <br /> Sub Contractor-Dfa( � Address E s Lic# 417-2zty Phone # <br /> TYPE OF WELL/PUMP: [] NEW WELL [] REPLACEMENT WELL [] MONITORING WELL # [[I OTHER �7 <br /> (] DESTRUCTION (] OUT-OF-SERVICE WELL [] GEOPHYSICAL WELL # X SOIL BORING (r-2 <br /> (] INSTALLATION [] WELL SYSTEM REPAIR (] CROSS-CONNECT REPAIR [] VAPOR EXTRACTION WELL # <br /> (] New [] Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL r—/c/ <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL 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 SEALM2-7)� SPECIFICATION <br /> (] IRRIGATION/AG [] OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> (] MONITORING GROUT SEAL PUMPED: [] Yes [] No CONCRETE PEDESTAL BY DRILLER: [] Yes (] No <br /> APPROX. DEPTH LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTRUCTIONIDRILLING METHOD: MUD ROTARY_ AIR ROTARY_ AUGER_ CABLE_ OTHER <br /> I hereby certify that I 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 agent's signature certifies the following: "I <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: II I certify that in the performance <br /> of the work for which this permit is issued, I shall employ persons subject to WORKMAN'S COMPENSATION Laws of California.-I THE APPLICANT <br /> MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 1209)488.3423. Complete drawing at Lower <br /> area provided. �I <br /> L- <br /> f } LTf3F7d 1�S 1 Date/a/1 r. <br /> S i gned X vV�/�1I�.L 1 � """"'�_' T i t l et5 <br /> DEPARTMENT USE ONLY Q /� <br /> Area <br /> Application Accepted By <br /> Grout Inspection By <br /> Date Pump Inspection By Date <br /> Destruction Inspection By Date Comments: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#1CASH RECEIVED BY 70ATE7�;PERMITISERVICE REQUEST NUMBER INVOICE <br /> �� k o <br />