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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVILt — <br /> ENVIRONMENTAL HEALTH DIVISION �� ,}} <br /> P O &388, 446 N. SAN JOAQUIN ST.. STOCkTON CA`UI.388 <br /> - (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FAOM DATE ISSUED <br /> IComplats is Trmpl"tal /or instaLL the work <br /> Application liance with San Joaquin County Developmentfor <br /> Title, Chapter 9 1115ermit to .3 and the Standards of SoneJoaquiind County Public. This tHealth <br /> t and <br /> made in comp <br /> Services, Environmental Health Division.` <br /> � <br /> City <br /> Job Address/or APN# �` -- Parcel Size/APN# <br /> Phone # <br /> Owner's Name <br /> ,� Address §� <br /> O• Lot( <br /> rl,~) ddress <br /> � Lic# -� Phone <br /> contractor 479b1-7 P4FT, <br /> Address e3 l L'c# <br /> Sub Contractor . S <br /> TYPE OF WELL/PUMP: [] NEW WELL [] REPLACEMENT WELL X MONITORING WELL # [] OTHER <br /> A ESTRUCTION [] OUT-OF-SERVICE WELL [I GEOPHYSICAL WELL # [] SOIL BORING <br /> [] INSTALLATION T] WELL SYSTEM REPAIR [I CROSS-CONNECT REPAIR [] VAPOR EXTRACTION WELL # V <br /> T] New ❑ Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL . <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE DF WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> [] INDUSTRIAL C] OPEN BOTTOM <br /> DIA. OF WELL EXCAVATION ! DLA. OF CONDUCTOR CASING <br /> DIA. OF WELL CASING <br /> [] DOMESTIC/PRIVATE [,YGRAYEL pp/SIZE TYPE OF CASING/STEEL/& <br /> [] PUBLIC/MUNICIPAL C] DRIVEN DEPTH OF GROUT SEALSPECIFICATION <br /> _ �iU'l�'fLf�_ <br /> [] IRRIGATION/AG [] OTHER GROUT SEAL INSTALLED BY ViL GROUT BRAND NAME . <br /> MONITORING GROUT SEAL PUMPED: [I Yes [] No CONCRETE PEDESTAL BY DRILLER: [].Yes. [] No <br /> APPROX. DEPTH LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTRUCTIONIORIlUNG METHOD: MUD ROTARY AIR ROTARY, AUGER_ CABLEDTHER_ <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, 1 shall not employ persons subject to WORK14ANIS'COMPENSATION <br /> Laws of California." Contractor's hiring or sub-contracting signature certifies the following: 111 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." THE APPLICANT <br /> MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT (20M 468.3423.r Complete drawing at lower area provided. y , <br /> Title SI �� Date �S <br /> Signed X <br /> PL9T P N ( raw to Scale Scale " to <br /> V' <br /> DEPARTMENT USE ON <br /> lY � � <br /> Application Accepted By - Det "Area <br /> Grout Inspection By Date Pump Inspection�By� Date <br /> Destruction Inspection By Date Comments: <br /> ACCOUNTING ONLY: AID# FAC# . <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKACASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> GD <br />