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APPLICATION FOR WELIJPUMP PERMIT <br /> f[�j' 'r <br /> SftH JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 80X 38$ 446 N. SAN JOAQUIN ST, STOCKTON, CA 95201.388 h <br /> (2091488-3420 <br /> NON.REFUNOABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> 10N1E <br /> made in compliance with San Joaquin County Development Title, Chapter 9-1115.3 and the standards of San Joaquin County Public Health <br /> Application is here by made to the San Joaquin Canty for a permit to construct and/or install the work described. This application is <br /> services, Environmental Health Division. _ <br /> city .'SAG I!•R'L i! <br /> Job Address/or APR# 1y Parcel Size/APR# <br /> � � SR'Mtr Phone # Zp/i'83S—Y07Z.i . <br /> Owner'sI Name / VVG{f K/SS / Address 1 yam'-772-3G2a li <br /> Iec"W641U Address ;50 �0�'L� .sem %DN_ Lic#/ Phone # <br /> Lic#Address y7 20 D Phone <br /> c} # <br /> Contractor"f <br /> i, TYPETYPE Of�P: [I NEW WELL I] REPLACEMENT WELL [7 MONITORING WELL # <br /> �'aTxER �fAtvD Ay4c — aaZIN`5 <br /> - [7 DESTRUCTION U OUT-OF-SERVICE WELL [7 GEOPHYSICAL WELL #.. E3 SOIL BORING <br /> LI INSTALLATION <br /> (I WELL SYSTEM REPAIR [7 CROSSCONNECT REPAIR FT FIRSTPOR YATERTLEVELOU WELL # <br /> C3 New [3 Repair H.P. DEPTH PUMP SET <br /> i <br /> (TYPE OF <br /> �i <br /> INTENDED USE TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> DIA. OF WELL EXCAVATION <br /> DIA. OF CONDUCTOR CASING <br /> [7 INDUSTRIAL C] OPEN BOTTOM DIA. OF WELL CASING <br /> i . [7 DCMESTIC/PRIVATE [7 GRAVEL PACK/SIZE__ TYPE Of CASING/STEEL/PVC <br /> -❑ PUBLIC/MUNICIPAL [7 DRIVEN - DEPTH Of GROUT SEAL <br /> 7b7-0 S�I t'f'kC& SPECIFICATION <br /> ❑ IRRIGATION/AG ❑ OTHER - GROUT SEAL INSTALLED BY IOu2• GROUT BRAND NAME <br /> GRCUT SEAL PUMPED: ❑ Yes �t No _CONCRETE PEDESTAL BY DRILLER: ❑ Yes ❑ No <br /> (7 MONITORING .1 I.. <br /> LOCKING CHESTER BOX/STOVE PIPE <br /> APPROX.DEPTH— <br /> PROPOSED CONSTRUCTIONIORIL❑NG METHOD: MUD ROTARY_ AIR ROTARY_ AUGER CABLE_ OTHER__ d - � <br /> I <br /> n Joaquin County Ordinances, i <br /> hereby certify that I have prepared this application and that thr <br /> Clio wok will be done in accordance with Sat <br /> certify that in Rules he performance of he warkOf hfor which this sCPermit is issued owner <br /> shallnotenQloy agent'ssignature <br /> sublect to�fWORK11ANies eSECCMPENSATION <br /> Laws of hat irthe Contractor's hiring or sub-contracting signature certifies the following: " I certify that in the performance r <br /> of the work for which this permit is issued, I shalt employ persons subject to WORKMAN'S COMPENSATION Laws of California." THE APPLICANT '! i <br /> MUST CALL 24 HUPS/IN AO}IANC� OR ALL REED INSPECTIONS AT(204)408 �3423. Complete drawing at lowerarea provided. <br /> 9�{l`8 ,L - (/� (J� Title r'�S( QcW Date <br /> signed X <br /> i <br /> e <br /> i <br /> ' DEPARTMENT USE ONLY <br /> Date ] ( .6 ( Area 7 <br /> Application Accepted Bye <br /> Date Pump Inspection By - Dale <br /> Grout Inspection By <br /> " <br /> Destruction [nspectionBy Date_4 Comments- <br /> FAC# - <br /> ACCOUNTING ONLY: AID# . <br /> PE CODES FEE INFO AMOUNT REMITTED CUECXIICASH RECEIVED By DATE PERMITISERYICE REQUEST NUMBER INVOICE <br /> 5 <br /> I <br />