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- - `- - • APPLICATION FOR WELLIPOMP PERMIT <br /> �- SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIC <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOAQUIN ST, STOCKTON, CA 96201-388 <br /> (209( 458-3420 <br /> i <br /> � MOM•RCiUMOABLE PERMIT EXPIRES 1 YEAR FROM GATE ISSUED <br /> I1 <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 /> made in compliance with San Joaquin County Develcpment Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Nealth <br /> services, Environmental Heath Division. �,/��� I, / <br /> I Job Address/or APN# /0�t✓cyd/S K.OAa City ��iC�-�Iv Parcel Size/APN# <br /> j Owner's Name�E� /�AF>llz� e Address ' /Q/SS �I IY YA JT +[n!✓ /4/Ce�f4�e- Phone # <br /> zi' cy .c Nv= I -2d/s <br /> J (�F Address/jcX S/ C2iu YIsTR _ Lic# �� �� Phone N•7C7-.3 IF <br /> Contractor {��/ ! L <br /> j Sub Contractor rjYY�I ej� 6f/'y6>•'glj:{F'l Address 4111 8'714 .SI Se CK v+tcwlu Lic# Phone #rl/6'�-77--j37/ <br /> I <br /> TYPE OF YELL/PUMP: El NEW WELL ❑ REoLACEMENT WELL (T MONITORING WELL # (I OTHER <br /> SOIL HORING <br /> [J DESTRUCTION (I CUT-OF-SERVICE WELL [I GEOPHYSICAL WELL # <br /> i ❑ INSTALLATION [T WELL SYSTEM REPAIR EJ CROSSCONNECT REPAIR ET VAPOR EXTRACTION WELL #__ <br /> New [7 Repair N.P. DEPTH PI1/P SET—FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS [ <br /> DIA. OF WELL EXCAVATION <br /> I [I INDUSTRIAL [) OPEN BOTTOM ION DIA. OF CONDUCTOR CASING_ — <br /> II [) DOMESTIC/PRIVATE ❑ GRAVEL PACK/SIZE__ TYPE OF CASING/STEEL/PVC 4tC �o I1�Nc� DIA. OF WELL NCASING <br /> E7 PUBLIC/MUNICIPAL [T DRIVEN DEPTH OF GROUT SEAL ;n <br /> (T IRRIGATION/AG [T OTHER <br /> GROUT SEAL INSTALLED BY VUHP GROUT BRAND NAME r'brllG.Rc <br /> [I MONITORING GROUT SEAL PUMPED: A Yes (T No CONCRETE PEDESTAL BY DRILLER: ❑ Yes No <br /> &�}}��,,`" / LOCKING CHESTER BOX/STOVE PIPE <br /> APPROX.DEPTH o�f� �O <br /> ' PROPOSED CONSTRUCTIONIORILUNG METHOD: NUO ROTARY_ AIR ROTARY_ AUGER__ CABLE_ OTHER_ <br /> j I hereby certify that I have prepared this application and that the work Will be done in accordance with San Joaquin County Ordinances, <br /> i State Laws, and Rules and Regulations of the San Joaquin County. Hoorn owner or licensed agent's signature certifies the following: "1 <br /> bject t <br /> certify that In the performance of the work for which this permit is issued, I shall not employ persons Is lsuert[fy that Nthe performance <br /> Laws of California." Contractor's hiring or sub-contracting signature certifies the following: <br /> of the work for which this permit is issued, 1 shall employ persons subject to WORKMAN'S COMPENSATION Laws of California." THE APPLICANT/) <br /> i MUST CALL 24 OUR1S/IN ADVANCE FOR ALL REDUIRED RSPECTIONS AT 12021 489-3423. Complete drawing loner Brea provided. <br /> � Y/L ^" ��•uLt r,� Title 2r <br /> Signed X <br /> II <br /> i ------------------- <br /> i <br /> DEPARTMENT USE ONLY <br /> Date `0 Area <br /> Application Accepted By <br /> Grout Inspection By <br /> Date Pump Inspection By Dale <br /> i <br /> Destruction Inspection By <br /> Date Comments: <br /> FAC# <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CASH RECEIVED BY DATE PERMITISERVICE REUUEST NUMBER INVOICE <br />