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AFFLICATION FOR WiWeunir rtnn«i N <br /> S, 0AMIN COUNTY PUBLIC HEALTH SERVICZS <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388. 445 N. SAN .1CACUEN ST., STOCKTON, CA 86201 388 PAYME14T <br /> (, 091 ail-=a RECEIVED <br /> NOWA541NDABLE PN?RNIIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> omplata is 110"0I 1 <br /> Aoplication is here by made to the San Joaquin Canty for a permit to Construct and/or install theIq c�C'�bea'-This applrcatian is <br /> made in complianca with San Joaquin County Oevei:paent Title, Chapter 9-1)i5.3 and the Standards Aa 44 gtun`Caunty Puoli� �ealth <br /> Services, Environmental Health Division. YYYYYYIIIIIIiiiiii E%��L�iL' , <br /> �^'� �C' EtvvlRo�v�'�- <br /> job Adaress/or APN* uL 8� ,E�[SZ' F C�+�7 til t CitytlYo k , Size/APN# <br /> Owner's flame / / r Address / o i-rd . ygV Phare S—Lr7�^ / <br /> ra.�J,�.�/v,i' �t� T/ o •' �//6-9.�y a7r U <br /> Contractor a.✓ .v '-Address1,01ici! Phare <br /> ' .Z C 4 L i c#C.S7-b?o7b/Phone 0 <br /> Sub Contractor ,' !7 r Address�j� � <br /> .. - .__S, Zt4 <br /> 'YPE OF WELL/PUMP- ❑ NEN WELL Q AL-PLACEMENT WELL q MONITORING WELL N p OTHER <br /> ❑ DESTRUCTION q OJT-OF-SERVICE HELL 13 GEOPHYSICAL WELL # (j SOIL BORING <br /> ❑ INSTALLATION p WELL SYSTEM REPAIR Q CROSS-CONNECT REPAIR VAPOR EXTRACTION WELL <br /> ❑ New p Repair N.P DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CDMSTRUCTIDN SPECIFICATTOKSVi <br /> Cl INDUSTRIAL ❑ OPEN 80TTCN OIA OF WELL EXCAVATION 5r DIA. OF CONDUCTOR CASING �- <br /> 0CME5TIC/PRIVATE [3 GRAVEL PACX/SI7.E TYPE OF CASI)NG/STEEL/PVC iyc- OIA. OF WELL CASING _ <br /> �l PUBLIC/MUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL 2-d ' SPECIFICATION <br /> 0 IRRIGATION/AG ❑ OTHER GROUT SEAL INSTALLED BY ID-/8-e ✓ GROUT BRAND NAME <br /> rl MONITORING GROUT SEAL PUMPED: P Yes p No CONCRETE PEDESTAL BY DRILLER ❑ Yes No <br /> APPROX DEPTH �� LOCKING CHESTER BOX/STOVE PIPE <br /> POSED CONSTRUCTIONIORILLUNI IIEMOO. MUD ROTAaT_ AIR ROTARY_ AUGFR rZ CARLE_ OTHER_ <br /> hereby certiTy that I have prepared this appt.cation and that the work will be done in accordance with San Joaquin County ordinances, <br /> state Laws, and Rules and Reguiatiom of the San Joaquin County. Nome owner or licensed agent's signature certifies the following: "I fl <br /> certify that in the performance of the work for wnich this permit is Issued,-1 shall not employ persons subject to WORKMAN'S COMPENSATION <br /> _aws of Caliform a." Contractor's hiring or sub-contracting signature certifies the following: " I certify that in the performance <br /> or the work for which this permit is issued, i s.At employ persons subject to WORKKAN'S CCMPENSATION Laws of California." THEAPPLICAMT <br /> ✓OUST CALL 24 H URS IN ADVANCE FOR ALLECUIRED UISPECTIONS AT¢O➢i 4MU23. Complete drawing at lower area provided. <br /> Signed X Title_..sr/'"gZCZT�4i'.!/df�rDates�_�c�� <br /> a <br /> 1 1 -A --A I Hl <br /> 4 <br /> DEPAiITNIEMT USE ONLY �y <br /> Application Accepted By Date + Area <br /> Grout Inspection By Date Pump Inspection 8y Date <br /> g ✓WDestruction Inspection 8y Date Camuents• 1 <br /> py <br /> ACCOUMTINC� ONLY. ,AID# FACS ff on <br /> PE CODES FEE INFO AMOUNT REIITCTEO l3i>: XrASH RECENJEO BY DATE PERIM(SERVICE REQUEST NUMBER INVOICE j <br /> -5� - 5fly <br /> 7L <br /> h <br />