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I _ i <br /> APPLICATION FOR WELLIPUMP PERMIT - - - -- -- <br /> SA4UIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> t P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCXTON, CA 96201.388 <br /> (2091468-3420 <br /> F NDN-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM OATEIISSUED <br /> (Complete ie Tripikatel <br /> tgpticatian is here by made to the San Joaquin C-linty for a permit to construct and/or,,:instaL[ the work described. This application is <br /> made in compliance with San Joaquin County Deve?ccment Title, Chapter 9-1215.3 and th'e Standards of San Joaquin County Public Health I <br /> services, Environmental Health Division. <br /> i <br /> ,ob Address/or APN# �_ ri-f7l A� r!2 S AA/.,) ri&1 city <br /> �D%RAC Parcel Size/APN# 2-31? <br /> Owner's Name 6&u Z-& PI LSA---r2-� Address eCXO'Ltx I IIDs g/� Phone Al <br /> �ontraetor 2� 1r Lie# J�/LZ(o g Phone # <br /> Address f ��.:._— <br /> II <br /> Sub Contractor Address qLic# Phone # <br /> I h � r <br />! i <br /> TYPE OF WELL PUMP- ❑ NEW WELL ❑ REPILAC'MENT WELL MONITORING WELLI!if � ❑ OTHER <br /> 0 DESTRUCTION p OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL ❑ SOIL BORING <br /> ❑ INSTALLATION ❑ WF---L SYSTEM REPAIR (3 CRASS-CONNECT REIPAIR ❑ VAPOR EXTRACTION WELL # <br /> 17 New ❑ Repair H.P. DEPTH PUMP SET II FT, FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ❑ INDUSTRIAL [3 OPEN BOTTCM DIA. OF WELL EXCAVATION r DIA. Of CONDUCTOR CASING <br /> t3 DOMESTIC/PRIVATE ❑ GRAVEL PACK/SIZE TYPE OF CASING/STEE P C I OIA. OF WELL CASIINNGn 1 <br /> rJZ � i <br /> [3PU5L1C/MUNICIPAL (3 DRIVEN DEPTH OF GROUT SEAL /Y Z II SPECIFICATION ## <br /> ❑ IRRIGATION/AG ❑ OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME � OCL K 'LJIR- P <br /> MONITORING GROUT SEAL PUMPED: [] Yes No CON <br /> I� CRETE PEDESTAL 9Y DRILLER: ❑ YcsNa <br /> u <br /> APPROX.DEPTH- LOCKING CHESTER BOX/ OVE PIPE ! <br /> pHOPaSED CONSTRUCTIONIDRILLiNG METHOD: <br /> HUD R074cY� AIR ROTARY AUGER CABLE II OTHER <br /> i hereby certify that !-have prepared this acc0cation 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. Hone 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 notl emp Lay I persons subject to-wORKmAN'S CCMPE14SATION <br /> Laws of CaLifornia." Contractor's hiring or sLb-contracting signature certifies the:lfollowi.ng: 11 I certify that in the performance ` <br /> of the work for which this permit is issued, I s:.alt employ persons subject to WORKMAN'S COMPE9SATION Laws of California." THEAPPLiCANT <br />'I IAUST CALL 24 HOURS ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12091459-3423. Complete dr-,., atl�kowe/r area provided. <br /> ��c�CL.7I Tit, ' LLC'C!'[.S2t Date <br /> Signed X <br /> 77 <br /> Ij ii <br /> DEPARTMENT USE ONLY <br /> Application Accepted By I �! Hate f Area <br /> J <br /> Oat Z� P�M7 InsCSiifrf'B Date r2 <br /> [foot Inspection By ,i <br /> Destruction inspection By Date Comments: <br /> !i II <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE C13 DES FEE INFO AMOUNT REMITTED CaECXjJCASN RECELVEO BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> Go `/ �7?"� <br /> r 1 <br /> 1 <br /> Ii <br />