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APPLICATION FOR WELLIPUMP PERMIT <br /> S,,._ AQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 8OX 388, 445 N. SAN JOAQUIN ST., STOCXTON, CA 95201.388 <br /> (209) 458.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Compl�n iw TriQlinn) <br /> ration is here by made to the San Joaquin County for a permit to construct and/or install the work described. This application is <br /> in compliance with San Joaquin County Develscment Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br /> vices, EnvirornentaL Health Division. <br /> Address/or APN# ` ��0Iv �')/-)l> C�tY �`�`IL Parcel SizeJAPN# <br /> rer's Name /�J IL I—r �l �����I�r`!`f Address6a= e-��ix �� Q Phone <br /> or�E:;•actor <br /> Address 2825 ��� " Z ° Phone # <br /> Address Lic# Phone # <br /> x Contractor <br /> t?E OF uELL/PUMP: NEW WELL (] REP'10EMEHT WELL 60ONITORING WELL # Mt,U3� Cl OTHER <br /> [] DESTRUCTION C] OUT-OF-SERV WELL [I GEOPHYSICAL WELL # [] SOIL BORING <br /> [] INSTALLATION [I WELL SYSTEM REPAIR (I CROSS-CONNECT REPAIR VAPOR EXTRACTION WELL <br /> FI <br /> Cl New (] Repair H.P. DEPTH PUMP SET FT. FIVAPOR <br /> WATER LEVEL <br /> !PE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> C' HDUSTRIAL CI OPEN BOTTOM DIA. OF CONDUCTOR CASING <br /> M DIA. OF WELL EXCAVATION <br /> (1 DCMESTIC/PRIVATE [] GRAVEL PACK/SIZE TYPE OF CASIAG/STEE / VC DIA. OF WELL CASING <br /> Z�� <br /> DEPTH OF GROUT SEAL '2 r SPECIFICATION <br /> Ste- 40 <br /> (] PUBLIC/MUNICIPAL CI DRIVEN <br /> GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> IRRIGATION/AG C] OTHER <br /> RR GROUT SEAL PUMPED: [I Yes No CONCRETE PEDESTAL BY DRILLER: (I Yes �S No <br /> �ONITORION <br /> A:%PROX. DEPTH LOCKING CHESTER BOX/STOVE PIPE <br /> =iDPOSED CONSTRUCTIONIORILLING METHOD: MUD ROTUY__ AIR ROTARY AUGEER CABLE__ OTHER_ <br /> hereby certify that I have prepared this apciication and that the owrtoier o Wer or ldicensedne in aagentasce with sigraturence�t�iesCthettollowingCe°I <br /> ;-ate Laws, and Rules and Regulations of the San Joaquin County. <br /> .•--rtify that in the performance of the work for ~With this permit is issued, I shall not employ persons subject to WORKMAN'S CCMrEormaION <br /> nce <br /> aws of California." Contractor's hiring or s:a-contractingrsons signature <br /> to certifies <br /> the <br /> NeSfoLLo COMPENSATION Laws f California.'rtify that in heTHE APPLICANT <br /> r the ,pork for which this permit is issued, I s`aLL ertQ[oy pe <br /> :&UST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED IASPECTIONS AT (2091 488.3423. Complete drawing at Lower area provided. <br /> Z,Title ! �i`I�'� Date <br /> -:fined X 1 1C L �Z lL y�i <br /> i <br /> 7-1 -:== <br /> I <br /> i <br /> DEPARTMENT USE ONLY <br /> Date C Z-7 �/ Area <br /> application Accepted By <br /> Trout Inspection By <br /> Date/2 23 9 By Date 3 �i <br /> destruction Inspection By Date Comments: _ 2— <br /> i ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECXi�ICASN RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER I INVOICE <br /> z20 xav <br /> i <br />