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APPLICATION FOR WELLIPUMP PERMIT <br /> N JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 SOX 388, 445 N. SAN JOAQUIN ST., STOCXTON, CA 95201.388 <br /> (209) 488.3420 <br /> NON•RE=t1NDABLE PERMIT EXPIRES 1 TEAR FROM DATE ISSUED <br /> (Campton is Triplican) <br /> Aoplication is here by made to the San Joaquin Cm—ty for a permit to construct and/or install the work described. This application is <br /> made in compliance with San Joaquin County Develccment Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br /> Services, Environmental Health Division. <br /> Job Address/or APN41moo 4 City ick I�L�Cl-o Parcel Size/APN# <br /> Owner's Name C1 Address Phone # <br /> l / n r <br /> Contractor 111" I �Pl� R Address Jx JO �I� vci (IT L i c# Phone # <br /> 7 <br /> Sub Contractor I <br /> VLA I( ( Address Y�� �'jl i ��tl-i � �_ Lir;* �/ i / 'Ci' Phone <br /> TYPE OF WELL/PUMP: [I NEW WELL [] RE?LACEMENT WELL MONITORING WELL # [] OTHER <br /> [] DESTRUCTION CJ OUT-OF-SERVICE WELL [I GEOPHYSICAL WELL # C] SOIL BORING <br /> C] INSTALLATION C] WELL SYSTEM REPAIR C7 CROSS-CONNECT REPAIR C] VAPOR EXTRACTION WELL <br /> [7 New [I Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> [] INDUSTRIAL [7 OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING <br /> [7 DOMESTIC/PRIVATE [] GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA. OF WELL CASING <br /> [] PUBLIC/MUNICIPAL [] DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> [J IRRIGATION/AG [] OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> [] MONITORING GROUT SEAL PUMPED: [I Yes 0 No CONCRETE PEDESTAL BY DRILLER: CI Yes C] Na <br /> APPROX. DEPTH LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CON STRUCTIONIORILLING METHOD: MUD ROTARY_ AIR ROTARY_ AUGER_ CABLE_ OTHER_ <br /> I hereby certify that I have prepared this apciication 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. Horne owner or licensed agent's signature certifies the following: "I <br /> his permit is issued, I shall not employ persons subject to WORKMAN'S CCMPENSAT <br /> certify that in the performance of the work for which tION <br /> mp <br /> Laws of California." Contractor's hiring or sLib-contracting signature certifies the following: " I certify that in the performance <br /> or the cork for which this permit is issued, I stall errploy persons subject to WORKMAN'S CCMPENSATION Laws of California." THE APPLICANT <br /> MUST CALL 24 HD RS IN ADVANCE FOR AL1 REQUIRED IXSAECTIONS AT (209) 488.3423. Corrplete drawing at lower .area provided. <br /> l <br /> / Title i � 3 �'–� 1 Date <br /> ��/� <br /> Signed X --ty" /7 �� /. C- / <br /> DEPARTMENT USE ONLY <br /> Date lv 7 L Area CIL <br /> Application Accepted By <br /> Date Pump Inspection By Date <br /> Grout Inspection By <br /> Destruction Inspection By me <br /> Date Cortnts: ��^ 5 #�f-7 f 3 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED a4i CASH RECEIVED BY GATE PERMITISEAVICE REDDEST%NUMBEIRJICE <br /> .SR005 <br />