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d <br /> APPLICATION FOR WELUPUMP PERMIT <br /> JOAQUIN COUNTY PUBLIC. HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 389, 445 N. SAN JOAQUIN ST.. STOCKTON, CA 95201-388 <br /> (209) 468.3420 <br /> MON•REFl1NDABLE PERMIT IXPIRES 1 YEAR FROM DATE ISSUED <br /> ( 1 <br /> Application is here by made to the San Joaquin Canty for a permit to construct and/or instatL 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 Ncalth <br /> Services, Environmental Health Division. <br /> ��,�y� Nt cltl - City S->� Ic �� Parcel Size/APN# <br /> Job Address/or APN# 7I� 'U 7 3 Z <br /> Owner's Name <br /> �,K..�l'C� -U'�� ddress 5�'✓"�-- Phone # <br /> } / mss' ddress 4'��� �2wc. J� L�� Phone 0�!6'4$Z'2��l <br /> Contractor ^^ z `V� ,�// -1 <br /> Sub Contractor <br /> �{� �vi(( � Address C'> 5� �(OU1$ Lic#65 /�62 Phone #7C7"�71f 'z�� <br /> TYPE OF WELL/PUMP: (� NEW WELL ❑ RE'LACEMENT WELL MONITORING YELL $• VAI ❑ OTHER <br /> [3 DESTRUCTION ❑ OUT-OF-SERVICE WELL [I GEOPHYSICAL WELL # [I SOIL BORING <br /> ❑ INSTALLATION [I WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL # <br /> ❑ New [3Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS / 1. <br /> DIA. OF WELL EXCAVATION ! b DIA. OF CONDUCTOR CASING 0 <br /> ❑ INDUSTRIAL L] OPEN BOTTOM �J <br /> 1:r—�F :�:rc � <br /> ❑ DOMESTIC/PRIVATE C] GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC O DIA. OF WELL CAS r <br /> S <br /> [] PUBLIC/MUNICIPAL C] DRIVEN DEPTH OF GROUT SEAL /5 ,� SPECIFICATION C z <br /> L W1+t GROUT BRAND NAME:Pb r��µ <br /> [] IRRIGATION/AG ❑ OTHER GROUT SEAL INSTALLED BY 7 1✓t✓i7 (� <br /> GROUT SEAL PUMPED: Yes DNo CONCRETE PEDESTAL BY DRILLER: Yes C] No <br /> MONITORING <br /> 1 LOCKING CHESTER BOX/STOVE PIPE YDS <br /> APPROX.DEPTH 7 O <br /> PROPOSED CONSTRUCTIONIDRIWNG METHOD: MUD ROTARY_ AIR ROTARY_ AUGER CABLE__ OTHER_ <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 /> ollowing: "I <br /> State Laws, and Rules and Regulations of the San Joaquin County. Home owner or licensed agent's ssignature <br /> on na ubject to�fWORKMANies eSfCOMPENSATION <br /> certify that in the performance of the work for which this permit is issued, I shall not employ ng „ I certifythat in the performance ,n <br /> Laws of California." Contractor's hiring or sub-contracting <br /> rsons signature <br /> subjectcertifies <br /> WORKMAN'SfCOMPENSATION Laws of California." THE APPLICANT <br /> of the work for which this permit is issued, I s�att employ pe <br /> MUST CALL 24 H URS ADVANCE f R ALL REGUIRF.O INSAECTiONS AT(209)488.3423. Complete drawing atLower provided. <br /> Signed X <br /> u Title Date <br /> DEPARTMENT USE ONLY <br /> Date _ Aree <br /> Application Accepted By <br /> Date Pump Inspection By Date <br /> Grout Inspection 8y '' <br /> Destruction Inspection By <br /> Date Comments: •V ✓YTS-f � 1�� <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKfiCASH RECEIVED BY DAT PER1dITISERYICE REST NUMBER IdVDICf <br /> 35or "o /9 65 <br />