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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ; <br /> ENVIRONMENTAL HEALTH DIVISION " <br /> P AU 388, 446 N. SAN JOAQUIN ST., STOCKTON, C 201.380 <br /> (209) 488.3424 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Compbte is T.iprkste) <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# "bA City -a Parcel Size/APN# <br /> owner's NameSTD- 1 Address Phone.# <br /> Contractor xt�Aer '�-aLf�t :> sS Address/gO3 62 Mf.diGM_4—J- Lic# Phone <br /> -felt�,���1 , -�a 40-1 �r t <br /> Sub Contractor r r � Address �} Li <br /> r A e ��/[GYw A,CA � Phone ## -- <br /> TYPE OF WELL/PUMP: ❑ NEW WELL 13 REPLACEMENT WELL EI MONITORING WELL # [I OTHER <br /> [I DESTRUCTION [I OUT-OF-SERVICE WELL €3 GEOPHYSICAL WELL # [I SOIL BORING <br /> INSTALLATION 0 WELL SYSTEM REPAIR (I CROSS-CONNECT REPAIR A VAPOR EXTRACTION WELL # <br /> [I New [3 Repair N.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> [3 INDUSTRIAL EI OPEN BOTTOM DIA. OF WELL EXCAVATION �� DIA. OF CONDUCTOR CASING <br /> I) DOMESTIC/PRIVATE [I GRAVEL PACK/SIZE TYPE OF CASIIIG/STEEL DIA. OF WELL CASING <br /> 13 PUBLIC/MUNICIPAL [I DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> 0 IRRIGATION/AG ❑ OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME 7(� - <br /> MONITORING r GROUT SEAL PUMPED: ❑ Yes E3 No CONCRETE PEDESTAL BY DRILLER: [I Yes [I No <br /> APPROX. DEPTH S _ LOCKING CHESTER BOX/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: 11 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 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT(209149-3423. Complete drawing at lower area provided. <br /> DEPARTMENT USE ONLY <br /> Application Accepted ay--Q _„ D a t Rl 7,;� GArea 12 <br /> Grout Inspection By Date Pump Inspection By Date <br /> Destruction Inspection By Date Comments: <br /> ACCOUNTING ONLY: AID# FAC# ' v <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK11CASH RECEIVED BY DATE PEAMiT15EAYICE REQUEST NUMBER INVOICE <br /> ;r <br /> t <br />