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- - - --- a..?PLICATI611 FOR WELLOTAP PERMIT <br /> $AD JOAQUIN CMITY PU9LIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 SOX 388. 445 U. SAES JOAQUIIE ST., STOCKTON, CA 96201-300 <br /> (209) 488.3420 <br /> NON-REFUNDABLE PERMIT EXP1 ES 1 YEAR FOq DATE 1SSU 0 <br /> This <br /> ion is <br /> or inotaLL the work <br /> Application is her* by made to the San Joaquin Cas�tY °Titte�,rChapter 9-1115 3 andmit to construct /the Standards i SaneJoaquiinn.County apubllictHealth <br /> made in compliance with San Joaquin County Devatcpmen <br /> Services, Environmental Health Division.. City <br /> [ panel Size/APN# �J <br /> Ca 5—T <br /> Job Address/or APNO 2-3 <br /> Phone 0-2Y 30 y <br /> (t B ►� Address /3o>G 3 <br /> Owner's N // Lic>B 7Z 0917 Phone 0 707 37q , <br /> L ►^G C µ` Address t.5 t <br /> Contractor / ` Phone +q?6y-7�Z-36� <br /> Sub Contractor ►� <br /> Address ,� r Lie#, <br /> OTHER <br /> TYPE OF YELL/PUMP 'NEW WELL C3 RE?LACEMENT WELL E3 NO <br /> WELL # d BORING <br /> p DESTRUCTION 0 plf-OF-SERVICE WELL [] GEoPNYSICAL WELL # Q VAPOR Spit BOERTRACTiCtI WELL A <br /> C3 INSTALLAT10ii p UMSYSTEM REPAIR iti CROSS-CONNECT REPAIR y <br /> I3 Now C] Repair H.P.1_ <br /> DEPTH PUMP SET FT. FIRST WATER LEVEL_ <br /> (TYPE OF PUMP1 <br /> WINDED ED USE TSE OF WELLc,DNSTAUn SPE GIFIC11an � K <br /> CIA. OF WELL EXCAVATION CIA. OF CONDUCTOR CASING <br /> 13 INDUSTRIAL (1 OPEN BOTTOM ZL� TYPE OF WELLcAsIEXCAVATION S �" q0 - DIA. Of WELL CASING <br /> p DOFIESTIC/PRIVATE )d GRAVEL PACK/SIZE DEPTH Of GROUT SEAL �r SPECIFICATION <br /> p PUBLIC/MUMICIPAL p DRIVEN GROUT BRAND NAME„13k sa l <br /> GROUT SEAL INSTALLED BY <br /> p [RRIGATIO /AG U OTHER GROUT SEAL PUMPED: ;J Yes p No CONCRETE PEDESTAL BY DRILLER: p Yes ' No <br /> p Y,OdITORiNG Gkrishie: box -_ <br /> APPROX.DEPTH 35 LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTRUCT1431UDNILUIIG 13UN00: MUO ROTARY_,_ AIR ROTARY_-+ AUGER CABLE_ OTHER_ <br /> 11 <br /> 1 hereby certify that I Novo prepared this application and that the work will be done in accordance wi11 t 11 h Son Joaquin County Ordinances, <br /> State Laws. and Rules mid Regulations of the San Joaquin County. Homo owner or licensed lay persons <br /> rsonsr+asubject to,WORKMANture certifies QSfCOMPENSATION <br /> certify that in the performance of the work for which this permit is issued, I shall not employ r, I certify that In the performance <br /> w persons subject to PiesWORKANTS COMPENSATION taws of Catifornia_ T14EAPPLICAUT/ <br /> Laws of California." Contractor's hiring or wb-contraetiny signature certifies the following- <br /> u <br /> of the work for which this permit is issued, t s..all "play pe <br /> BUST CALL I; URS is ADVANCE FOA LL REQUIRED 1BSPECTIOUS AT I28B1 488'3423. Complete drewinB at lo ` area Provided• Date <br /> Title <br /> Signed X �(�`-' <br /> DEPARTdENT USE OCLY A9C' <br /> Pee <br /> DatQQQ <br /> Application Accepted By Date <br /> • Date Pump Inspection <br /> Grout inspection By <br /> Destruction Inspection By <br /> Date---- <br /> Destruction <br /> ate _ C0°^ nts• <br /> ACCOUNTING ONLY: <br /> AIDO FAC# 3 ,� <br /> PE CODES FEE F0 AMOUSIT REMITTED giECICACASH RECECVED BY DATE PERNIiTISERVICE REQUEST HUISBER HlvalCE <br />