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— a f <br /> APPLICATION FOR%11ELL11 UMP PERMIT -- <br /> M JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1--�' <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOA(1UIN ST., STOCXTON, CA 95201.388 <br /> (209( 488-3420 <br /> 14.1x- <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE.ISSUEO _ i (;: 40 N� <br /> Ior�Bl��I J <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 Develcfinent Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br /> Services, Environmental Health Division. l <br /> ��, £Cgs :,, S� / �� City S-I�e-K-a0 Parcel Size/APN# <br /> Job Address/or APN# ., <br /> (.� 6(' STDC-t�"T'OrJ Address Phone # <br /> Owners Name ,,JJ <br /> yJ Address S( Vt /� Lic# 7430904 Phone # 7eT,3�'f-2W�S <br /> Contractor. 1 <br /> E �n ddress Sex J�'CrZ- SfPC.j— Lic# Phone #20'172,-3620 <br /> Sub Contractor <br /> TYPE OF WELL/PUMP: [J NEW WELL ❑ REPLACEMENT WELL (] MONITORING WELL # (] OTHER t l2. <br /> ' U DESTRUCTION [] OUT-OF-SERVICE WELL U GEOPHYSICAL WELL # / <br /> SOIL BORING <br /> (] INSTALLATION Q WELL SYSTEM REPAIR (] CROSS-CONNECT REPAIR [] VAPOR EXTRACTION WELL # <br /> (] New ❑ Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL (1 <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> i� <br /> QINDUSTRIAL (] OPEN BOTTOM <br /> DIA. OF WELL EXCAVATION_ DIA. OF CONDUCTOR CASING <br /> [3 DOMESTIC/PRIVATE (] GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC IJ/t DIA. OF WELL CASING <br /> (] PUBLIC/MUNICIPAL [] DRIVEN DEPTH OF GROUT SEAL -'CO l3c,TO&A SPECIFICATION <br /> [I IRRIGATION/AG ❑ OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME PorTL.)kA/0 <br /> A MONITORING GROUT SEAL PUMPED: [] Yes (K No CONCRETE PEDESTAL BY DRILLER: 0Yes No <br /> APPROX.DEPTH Iz-j LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTRUCTIONIDRILLING METHOD: MUD ROTARY_ AIR ROTARY_ AUGER__ CABLE— OTHERL-64t <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. 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 COMPENSATION <br /> Laws of California." Contractor's hiring or sib-contracting signature certifies the following: " 1 certify that in the performance <br /> of the work for which this permit is issued, I shaLL employ persons subject to WORKMAN'S COMPENSATION Laws of California." THE APPLICANT <br /> MUST CALL 24 HO AS IN ADVANCE FOR ALL REQUIRED 11SPECTIONS AT(209)488.3423. Complete raving at Lower .area provided. <br /> el-I_ Title �l�c�c� /f Date3L39,? <br /> Signed X <br /> DEPARTMENT USE ONLY �j <br /> Date �� r 19DateApplication Accepted By <br /> Date 7!j Pump Inspection By Date <br /> -Pry <br /> Grout Inspection By ''//v <br /> Destruction Inspection By Date Comments: v/ �� � <br /> e ` �— 0 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT AEMITTED C7iECKtfCASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> 350/ � � ,3• .- DJ � <br />