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APPLICATION FOR WEWVUMP PU MIT <br /> SA�al11N COUNTY Pt38LIC HEALTH SERVICES . <br /> YIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 38$ 445 N. SAN JOAaaw ST, STUCXTaN, CA 95201 388 <br /> {209} 458.3420 <br /> NOM REFUNOABIE PERRIT EXPIRES 1 YEAR FROM GATE ISSUED <br /> .,c.I, c a t i o n is 'i e r e by 'Ode 0 Che San Joaquin G�nry for (Caalplatl IN <br /> nrrptiance +Itn San " w11 <br /> nade In C ' a permit to Construct and/or Install the work described This appiication Is <br /> J°aquin County Deveicptsent iitie, Chapter 9-1115 3 and the Standards of San Joaquin cowry a,,oIIC lealth <br /> ervices, Enviroriiental Health Division <br /> co Aoaress/or APNg � RS Ce 7_ <br /> /1 ' C Ctry �S�O (rd� Parcel Stze/APN# <br /> +ner's flame /[/J <br /> N Address"'a <br /> .. W ' / <br /> _ontractor a Phone Q <br /> r,'zo Address d/ Go dP d/C'oa ,'l/ �q► <br /> V <br /> I` ' /] J <br /> �o Contractor f(4i el"( J <br /> Address A!d ?hare x <br /> / t �' Lictt O O phone D <br /> YPe OF WELL PUMP I] NEW WELL V <br /> ❑ REPLACEMENT WELL q MONITORING WELL # <br /> X DESTRUCTION U SORER <br /> ❑ CUT-OF-SERVICE WELL (2 GEOPHYSICAL WELL # [] SOIL BORING <br /> rl INSTALLATION ❑ ,F—L SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR <br /> ❑ VAPOR EXTRACTION WELL <br /> [I New (I Repair H ? DEPTH PUMP 5E7 <br /> TYPE OF PUMP} —FT FIRST WATER LEVE! <br /> 9TEYUEO USE TYPE OF WFLE CONSTRUCTION SPECIFICATIONS <br /> C��U.S%`1 G Ao.v, (or wS �-GRAVEL� ffa�r CtJr�r s <br /> uQUSTRtAL r, OPEN 30TTC#4 DIA OF WELL EXCAVATION <br /> JCHEST'C/p41t'xi>r i DIA OF CONDUCTOR CASING <br /> € PACX/SIZE TYPE OF CASING/STr:EL/PVC <br /> ?UbLIC/MUNIC PAL r — - _ OIA OF WELL CASoHG <br /> ] DRIVEN DEPTH OF GROUT SEAL <br /> IRRIGATION/AG i SPECIFICATION <br /> ( OTHER GROUT SEAL INSTALLED BY <br /> 40NITORING CRCt]T BRAND NAME <br /> GROUT SEAL PUMPED, (I Yes ❑ No CONCRETE PEDESTAL 3Y DRILLER Yes t] Na <br /> APPROX DEPTH LOCKING CHESTER SOX/STOVE PIPE <br /> 'qI '"CO CUNSTRUCTIONMRILLING METHOD NUD ROTARY AIR ROTARY AUGER fef CABLES OTHER_ <br /> iereoy certiry that I have prepared this apcL cation and that the work wiLL be done in actor <br /> .ate ''Law5, ar)a Rules and Regutattons at the pet Joaquin County. Home owner or licemed agent'stsignaturenceroriries the ollouing <br /> Ginn Ccu'itY Ordinances <br /> er-�Ty that to she perrormance or the work ror wnich this permit to issued, I shall not eoipioy persons subject to '�RKMAN'S C�lPE4SATION <br /> a s or Callrarm a " Contractor's hiring or stab-contracting signature certifies the foltowing: " i certiry that in he performance <br /> re tore Or' .iliN his permit is issued, I s`all eaptoy Per$*= sub]ect to WORKMAN'S COMPENSATION Laws or Cal itornia TqEAPPLICAXT <br /> aI15T CALL 24 H URS iN ADVANCE FOR AL REOU[REA i!<SPECTIONS AT 12091 4E11-3423. Comptete drawing at lower area providea <br /> Tttie Alt'or _iGl r Dat <br /> f� <br /> i II I f I II <br /> 1177� I i <br /> DEPARTMENT USE ONLY <br />—1 kation Acctptep 3y <br /> rout fns Date Area <br /> pec-ion By Data <br /> � PurQ Inspection By Dare <br /> rs'ruc-,on inspec-ion 3y F /1/111 2 <br /> Data Coa�itents �i'Ll(/ UL!/��y 7"- <br /> ACCOUNTING ONLY AID# FAJC* <br /> PE CODES EEE INFO AMOUNT REMITTED CiiEiDXI(CASH RECEIVED By DATE PERM91SERVICE REQUEST NUMBER INVDiCE <br /> 2, a _UA ��7 �2� o -- r' <br /> I <br /> 1 I � <br /> I If <br />