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APPLICATION FOR WELLIPUMP PERMIT R ^p� " <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SER S rIYEU <br /> ENVIRONMENTAL HEALTH DIVISIONUNTY <br /> 9�F <br /> P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201-388 SAN JOA��)N pa1q.96 <br /> (209) 4683420 PL)EILIC HEALTH SERVICES <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH DIVISION <br /> (Complete is Triplicate) <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# //2/.7/ city ��/ D/l/ parcel Siz/e/APN# �— <br /> Owner's NameF� /T//L!-y �� 9 2.Address 2/S/ r�OU.U �'/ U� I�L/ U,7 <br /> �, Phone # <br /> contractor/7�//Cl /fir L7��l�i/�/,i(/(/hsZ'P.L,W Address�.3 W A4"�C�-11U -44 2Z� GL •� <br /> �N n Lic# p�� Phone # <br /> Sub Contractor �6C� � '2/`�/�L Address /ZSO C. /Leln)Ai Lic# "/ 1'2 /O Phone # <br /> Altl �— <br /> TYPE OF WELL/PUMP: [I NEW WELL [3 REPLACEMENT WELL [I MONITORING WELL # [I OTHER <br /> [I DESTRUCTION ❑ OUT-OF-SERVICE WELL H GEOPHYSICAL WELL # <SOIL BORING _ <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR [I VAPOR EXTRACTION WILL # <br /> H New [I Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> INDUSTRIAL [I OPEN BOTTOM DIA. OF WELL EXCAVATION I'/ZS DIA. OF CONDUCTOR CASING <br /> 0 DOMESTIC/PRIVATE H GRAVEL PACK/SIZE_ TYPE OF CASING/STEEL/PVC DIA. OF WELL CASING All+ <br /> H PUBLIC/MUNICIPAL [IDRIVEN DEPTH OF GROUT SEAL /CJ7Jt, jQ�-� SPECIFICATION <br /> 0 IRRIGATION/AG ❑ OTHER GROUT SEAL INSTALLED BY N/q GROUT BRAND NAME 71470 <br /> MONITORING 2 / GROUT SEAL PUMPED: [I Yes I�T-'No CONCRETE PEDESTAL BY DRILLER: ❑ Yes ❑ No <br /> APPROX. DEPTH 3o LOCKING CHESTER BOX/STOVE PIPE ' <br /> PROPOSED CONSTRUCTIONIORILLING METHOD: MUD ROTARY_ AIR ROTARY_ AUGER_ CABLET <br /> _ OTHER �7 P. /. <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. Hage owner or Licensed agent's signature certifies the foLtowing: "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: It I 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 IN AQVANGH911 ALL REauiRFs INSPECTIONS AT(209)4983423- Complete drawing^Lstlower area rovj ded. <br /> Signed X TitLe/LC�� Date* <br /> r � u <br /> DEPARTMENT USE ONLY �7 �7 q <br /> Application Accepted By <br /> Date L-1 / -/ 6 Area 6F(I <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 CHECK#ICASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> s C, �� -5�6 098 <br />