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_APPLICATION FOR WELLIPUMP PERMIT <br /> SA' 4QUIN COUNTY PUBLIC HEALTH SERVICES <br /> ',.�NVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCXTON, CA 96201.388 <br /> (2091468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (ComPlate in 11111111110111 <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 Deve(cpment Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br /> services, Environmental Health DirvisiYon.` y- ,( <br /> Job Address/or APN# / to / V We.s/ ' c,sl . City rctGN AA Parcel Size/APN# <br /> Owner's Name�� Address / &O S'U Park .Sy: /��aittl �Q _ Phone #S(0 43(04=3Gl 3 <br /> .ontractor Zo^/ �ie/sr '✓.�7lNTo�ddress a 3/ //�� Lic# _ Phone #y(!i`93 '2 <br /> rs. -Y a x a (y �a l�l �- <br /> Sub Contractor .T` �� Vr.'11•;✓c Address,[#,a.✓ !ia ..de a Lic# Phone <br /> 'YPE OF WELL/PUMP: (3 EW WELL ❑ REPLACEMENT WELL "NITORING WELL # 13 OTHE <br /> (] ESTRUCTION (] OITT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL # ❑ SOIL BORING <br /> [] INSTALLATION ❑ UUL SYSTEM REPAIR Cl CROSS-CONNECT REPAIR [3 VAPOP EXTRACTION WELL <br /> [3 New (3 Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> ;TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> r] INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING <br /> :] DCMESTIC/PRIVATE [] GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC P V L DIA. OF WELL CASING <br /> _] PUBLIC/MUNICIPAL [] DR:VEN DEPTH OF GROUT SEAL SPECIFICATION A/e a 'r G le rl f .. y` <br /> IRRIGATION/AG [] OTHER GROUT SEAL INSTALLED BY.gt lL e r GROUT BRAND NAME <br /> MONITORING GRCUT SEAL PUMPED: ❑ Yes )j No CONCRETE PEDESTAL BY DRILLER: Vyes (] No <br /> APPROX. DEPTH— _ LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTRUCTIONIORILLING METHOD: MUD ROTARY_ AIR ROTARY_ AUGER-kz�CABLE_ OTHER_ <br /> : 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: "1 <br /> certify that in the performance of the work for which this permit is issued, I shall not employ persons subject to WORKMAN'S CCMPENSATION <br /> _aws of California." Contractor's hiring or sub-contracting signature certifies the following: " I certify that in the performance <br /> of the cork for which this permit is issued, I s`all employ persons subject to WORKMAN'S COMPENSATION Laws of California." THEAPPLICANT <br /> MUST CALL 24 9OURS IN ADVANCE FO ALL REQUIRED UISPECTIONS AT(2091488-3423. Complete drawing at Lower area provided. <br /> Signed X Title S'!.✓l _ Date <br /> I <br /> i <br /> DEPARTMENT USE ONLY ./ <br /> Application Accepted By 1 �M/l/�--� Date � U Area <br /> Grout Inspection By Date Pump Inspection By Date <br /> F <br /> Destruction Inspection By Date Comments: <br /> ACCOUNTING ONLY: AID# FAC# <br /> i <br /> PE CODES FEE INFO AMOUNT REMITTED CASH RECEIVED BY DATE PERMITISERVICE REGUEST NUMBER INVOICE <br /> 35O rI 3 / <br /> i �� <br />