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APPLICATION FOR WEL11PUMP PERMIT <br /> ( JOA(1UIN COUNTY PUBLIC HEALTH SERVICESQ.- <br /> ENVIRONMENTAL HEALTH DIVISION <br />{ i <br /> P a BOX 368, 445 N, SAN ,IOAaUIN ST.. STOCXTON..CA 95201-388 <br /> I (209} 468-3420 . <br /> iI <br /> NOM•RMNI3ABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> ICampiets in Triplintel <br /> Application is here by made to the San Joaquin Cxncy for a permit to construct and/or install the work described. This application is r <br /> made in compliance with San Joaquin County Devetopment Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br /> Services, Environmental Health Division. : <br /> Job Address/or APN# n City rCC i; Parcel Size/APN# <br /> i Owner's Name Address � i Phone # <br /> `M I t�. LifFr <br /> E Contractor �/ [CCS Address i 1111 x(fM( Lic# Phone # <br /> U '' (�/� <br />� Sub Contractor nnllli I`�� Addres � �tr�[1! It II. %ri c# � � [��!✓ Phone # <br /> — <br /> U <br /> TYPE OF WELL PUMP: [3 NEW WELL ❑ REQ!1CIEMEHT YELLMOHITORING WELD ` [I OTHER <br /> I` (] DESTRUCTION (I OUT-OF-SERVICE WELL CI GEEOPHYSICAL WELL 9 I! CI SOIL BORING <br /> I <br /> (] INSTALLATION ❑ W-L SYSTEM REPAIR CI CROSS-CONNECT REPAIR II CI VAPOR EXTRACTION WELL # <br /> L II New ❑ Repair H.P. DEPTH PUMP SET_5 LFT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br />� i <br /> i- INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ❑ INDUSTRIAL [I OPEN BOTTOM! DIA. OF WELL EXCAVATION � 11DIA. OF CONDUCTOR CASING <br /> [I DCMESTIC/PRIVATE C1GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC I! ?DIA. OF WELL CASING <br /> (] PUBLIC/MUNICIPAL {] DRIVEN DEPTH OF GROUT SEAL �I �j,SPEC3FECATION <br /> (] IRRIGATION/AG C] OTHER GROUT SEAL INSTALLED BY ��i. 'I!GROUT BRAND NAME <br /> IGROUT SEAL PUIiP£7: ❑ Yes CI No ''CONCRETE PEDESTAL BY DRILLER:.[] Yes [] Na <br /> (I MONITORING q <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTRUCTIONJORILLING METHOD: NUD ROTARY_ AIR ROTARY_ AUGER CABLE! OTHER <br /> I hereby certify that I have prepared this application and that the work will be donepin accordance with San Joaquin County Ordinances, <br /> State Laws, and Rules and Regulations of the San Joaquin County. Home owner ar licensed agent's signature certifies the fotlawing: "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 szb-contracting signature certifies the fallowing: " I certify that in the performance l 5 <br /> of the work for which this permit is issued, I s:alL employ persons subject to 4CRKMAN"'S COMPENSATION Laws of California." THE APPLICANT <br /> }RUST CALL 2 URS IN ADVANCE FOR ALL REO RED INSPECTIONS AT(209)4U-3423. Complete cirlawing at tower area provided. <br /> Data/ <br /> Signed X / x: T;itLa ' <br /> I k (A <br /> II1 = <br /> II 3 <br /> I LL I <br /> DEPARTMENT USE ONLY <br /> i <br /> Application Accepted By i Date Ares <br /> t <br /> Date Pump Ins Ipection 'ey Date - <br />` Grout Inspection By i <br /> Destruction Inspection By Date Comments: <br /> ACCOUNTING ONLY: REQ# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CI{ CASH RECEIVED BY DATE it PERMETISERYICE REQUEST HUMBER INVOICE <br /> l h <br />