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' APPLICATION FOR WELaNMP PERMIT <br /> -� SAN JOAOUIN COUNT!' PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION REC"ONED <br /> P O BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201-388 DEC <br /> (209) 468.3420 �gj�A I <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED FNV %�I,I�j� �EALTH <br /> (Complete is Triplicate) ! / lkg s <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. .�/y,,,,���,l` <br /> Job Address/or APN# <br /> W. city �l � - _ Parcel Size/APN# <br /> r <br /> , f1.�, Phone # <br /> Owner's Name T ✓ rte-- Address '? <br /> Contractor ifGr+l -'RFS b `��"Af''S Address ��D� f/�f$� �± Lic# Phone # —, p <br /> p �� L i c#r`E h Phone# �� ^4.3 0 <br /> Sub Cantractor/y� / X11` Addressa,a-t�+�o a4 - — <br /> TYPE OF WELL PUMP: �Y NEW WELL C7 REPLACEMENT WELL MONITORING WELL # [7 OTHER <br /> C] DESTRUCTION 17 OUT-OF-SERVICE WELL I1 GEOPHYSiCAI WELL # C] SOIL BORING <br /> C7 INSTALLATION C7 WELL SYSTEM REPAIR [I CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WILL <br /> 0 New [1 Repair H.V DEPTH PUMP SET FT. FIRST WATER LEVEL' <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> DIA. OF WELL EXCAVATION fr DIA. OF CONDUCTOR CASING a� <br /> [7 INDUSTRIAL [} OPEN BOTTOM „ <br /> 1] DOMESTIC/PRIVATE [7 GRAVEL PACK/SIZE TYPE OF CASITIG/STEEL/6DDIA. OF WELL CASING _ <br /> C] PUBLIC/MUNICIPAL C7 DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> [7 IRRIGATION/AG [7 OTHER GROUT SEAL INSTALLED-BY GROUT BRAND NAME- ekZ,+-tr1 <br /> MONITORING GROUT SEAL PUMPED: C) Yes Il No CONCRETE PEDESTAL BY DRILLER: 11 Yes 17 No <br /> APPROX. DEPTH LOCKING CHESTER STOVE PIPE <br /> PROPOSED CONSTRUCTIONIORILLING 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: " I certify that in the performance <br /> of the work for which this permit is issued, I,sha[L employ persons subject to WORKMAN'S COMPENSATION Laws of California." THE APPLICANT <br /> MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT (208)46&3423. Complete drawing at Lower aree provided. I 4Z/, t4� <br /> Signed X iot T lS Date <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Areas <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 CHECKMCASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br />