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APPLICATION FOR WEWPUMP PERMIT <br /> SA' TAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> Nft-wENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 446 N. SAN JOAQUIN ST, STOCKTON, CA 96201.388 <br /> (209) 468.3420 <br /> NON•REFUNOABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <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 Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br /> services, Environmental Health Division. 1 1 �+ <br /> Job Address/or APN#_ I O LS (, .54- � `+� J��_ City Tv� n Par``celA/Size/APN# <br /> Owner's Name. M 5 . IV tD �[PS Address L8l0 rjovNe�SVtI� R04(].P*-V Phone # <br /> It f'- 1O ll Gol$e4Y}-ln ?adk.W�y �c <br /> contractor L+^�^�^�^ t'1A�1�YOKVN 2N'tA' Address ( Dela o t l5 C.De Lic#C�.l'-�a it'���J� Phone # L5 10 �C1—a�70 <br /> ' ,`,A l` P 0.Box 5t Rio�/is S Lic# 7A0. 04- Phone # 7 314 12%I S <br /> Sub Contractor �� \Q"D of I� Address <br /> TYPE OF WELL/PUMP: 0 NEW WELL 0 REPLACEMENT WELL 0 MONITORING WELL # 0 OTHER -�pp / <br /> 0 DESTRUCTION 0 OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL # SOIL, BORING/ t/G`4. 4C.14 `�I) <br /> /� <br /> 0 INSTALLATION C3 WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR []VAPOR EXTRACTION WELL # <br /> N A _ 0 New 0 Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> (I INDUSTRIAL U OPEN BOTTOM DIA. OF WELL EXCAVATION 3 it DIA. OF CONDUCTOR CASING AS A <br /> (I DOMESTIC/PRIVATE 0 GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC �)/A DIA. OF WELL CASING N IA <br /> [I PUBLIC/MUNICIPAL 0 DRIVEN DEPTH OF GROUT SEAL x ;L0 '57+ SPECIFICATION ke-r�G'F CPtnn�tA+ <br /> �� <br /> () IRRIGATION/AG (I OTHER GROUT SEAL INSTALLED BY DYAt?1/ GROUT BRAND NAME ?o V-11k4tnA <br /> () MONITORING GROUT SEAL PUMPED: 0 Yes )( No CONCRETE PEDESTAL BY DRILLER: )(Yes 0 No <br /> APPROX.DEPTH PLO LOCKING CHESTER ROX/STOVE PIPE <br /> PROPOSED CONSTRUCTIONIORILUNG METHOD: MUD ROTARY_ AIR ROTARY_ AUGER. CABLE_ OTHER ✓ (G e-c)-PY-ADbe� <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. Horne 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: " 1 certify that in the performance <br /> or the work for which this permit i issued, I stall employ persons subject to WORKMAN'S COMPENSATION Laws of California." THEAPPLICANT <br /> MUST CALL 24 HOUR N ADYA CE FOR L REQUIRED IASPECTIONS AT(2091488-3423. Complete drawing at lower area provided. <br /> Sign X TitleY ',o& E� (O�t i $.T Date2-jt7'� <br /> //�J/DEPARTMENT USE ONLY <br /> Application Accepted By L i,l' ' -- Date O21/-IqQu Areae <br /> Grout Inspection By Date ump Inspection By Date <br /> Destruction Inspection By Date Comments: <br /> ACCOUNTING ONLY: AID# I FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECXJICASH RECEIVED BY DATE PERMITISERVICE REDUEST NUMBER INVOICE <br /> 350T-77-co 14H51 TLrw 02 I:r Ol 4. 8 ` c <br />