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APPLICATION FAIR WELLIPUMP PERMIT RECENED <br /> AN JOAaUIN COUNTY PUBLIC HEALTH SERVIC <br /> Y ENVIRONMENTAL HEALTH DIVISION DEC '' .1995 <br /> P 0 BOX 388, 445 N. SAN JOAaUIN ST, STOCKTON, CA 96201.388 " ENVIRONMENTAL HEALTH <br /> (209) 4S"20 PIRMIT/SERVICH <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Compton in Triphcaw) <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. ' <br /> Job Address/or APN# W• City �/� Parcel Site/APN <br /> # <br /> owners Name <br /> Address S Phone <br /> Address �' N41W Cil1 C4 L i cff Phone <br /> Contralto ' <br /> sub Contractor �I' Address Li. Ph�` # <br /> TYPE OF WELL/PUMP: <br /> NEW WELL E3 REPLACEMENT WELL MONITORING WELL # C7 OTHER <br /> I] DESTRUCTION C] OUT-OF-SERVICE WELL C] GEOPHYSICAL WELL # C] SOIL BORING <br /> [} INSTALLATION "C3 WELL SYSTEM REPAIR E) CROSS-CDNNECT REPAIR I] VAPOR EXTRACTION WELL # <br /> [] New [] Repair ',H.P_" DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Q kf <br /> C3 INDUSTRIAL C7 OPEN BOTTOM <br /> DIA. OF WELL EXCAVATION V DIA. OF CONDUCTOR CASING , ' <br /> C] DOMESTIC/PRIVATE C7 GRAVEL PACK/SIZE TYPE Of CASING/STEEL) <br /> DIA. OF WELL CASING _ C2 " <br /> [] PUBLIC/MUNICIPAL C] DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> I] TRRIGATIDN/AG I7 OTHER GROUT SEAL INSTALLED BY �d <br /> GROUT BRAND NAME MONITORING L _ <br /> +; GROUT SEAL PUMPED: C] Yes I] No CONCRETE PEDESTAL BY DRILLER:. 13 Yes 11 No I. } <br /> APPROX. DEPTH LOCKING CHESTER�C/�TOVE PIPE <br /> Lff <br /> PROPOSED CONSTRUCTIONIORILLING METHOD: MUD ROTARY! AiR ROTARY_ AUGER CABLE OtHER_ <br /> ng- <br /> I hereby certify that I have prepared this application and that the work will be done in accordance xith San Joaquin County Ordinances, <br /> oLLowi <br /> State Laws, and Rules and Regulations of the San Joaquin County. Home owner or licensed agent'fsignons subject toature cert�fWORKMANie eSfCOMPENSATION` <br /> certify that in the performance of the work for which this permit is issued, I shall not employ pe <br /> Laws of California." Contractor's hiring or sub-contracting rs�n subject ure certifies <br /> Ne5fCOFfpEN5AT10N Laws ofollowing: 11 1 }California_fy that in °h THEAPPLCANT <br /> of the work for which this permit is issued, I shall employ pe <br /> MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12001 488.3423. Complete drawing at lower gree provided. y2 lr <br /> ,`�L� Q,rjr; , } Title l0 J Date 1" <br /> i o X - /""`v��" i <br /> I <br /> Li <br /> DEPARTMENT USE ONLY <br /> lication Acce ted B Date Area <br /> App p Y <br /> Grout Inspection By Date Pump Inspection By Date. <br />' Date Comments- <br /> Destruction Inspection By <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKVCASH RECEIVED BY. DATE PERMITISERVICE REQUEST NUMBER INVpICE <br /> Zia hNah3a <br /> f <br />