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APPLICATION FOR WEL1.'PUMP PERMIT <br /> ,.WA JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH OIVISION <br /> P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCXTON, CA 95201.388 <br /> (209) 468-3420 <br /> NON.RL=UXDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete is Triplicate) <br /> Application is hereby made to the San Joaquin z my for a permit to construct and/or install the work described. This application is <br /> made in compliance with San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br /> Services, Environmental Health Division. 5. -V— flO"`Lt <br /> (� u1, (��s..� L;r+ )'jy�o�' �� City `�O`�x Parcel Size/APN# 6'S aC.-c$ <br /> Job Address/or APN# �3 � � < o <br /> (T(*')Owner's Name � eVrO` P� L'r� Address I 3,< so'S'q SwQa..o.+, CA JgTt3 -095 Phone # g`IZ -60 <br /> Contractor <br /> (�o,�.s Qt�c�a�rna.{ Address 1'207Kip—• .k,� woodla..i,tp?S� c# 25�3� Phone #( �3'30-43 <br /> Sub Contractor Address Lie# Phone # <br /> TYPE OF 'BELL/PUMP: XNEW WELL ❑ R-=LACEMENT WELL MONITORING WELL # L ❑ OTHER <br /> II DESTRUCTION ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL # ❑ SOIL BORING <br /> lI INSTALLATION ❑ LEL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL # 1 <br /> ❑ New ❑ Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE WCONSTRUCTION SPECIFICATIONS ft )) <br /> DIA. OF CONDUCTOR CASING <br /> (3 INDUSTRIAL [I OPEN BOTTOM DIA. OF WELL EXCAVATION 2� <br /> ❑ DOMESTIC/PRIVATE ❑ GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC PVC DIA. OF WELL CASING <br /> ❑ PUBLIC/MUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL <br /> '51 SPECIFICATION <br /> ❑ IRRIGATION/AG ❑ OTHER <br /> GROUT SEAL INSTALLED BY ATEb GROUT BRAND NAME <br /> MONITORING ( GROUT SEAL PUMPED: C3 Yes ❑ No CONCRETE PEDESTAL BY DRILLER: ❑ Yes El 40 <br /> g <br /> LOCKING CHESTER BOX/STOVE PIPE <br /> APPROX. DEPTH <br /> PROPOSED CONSTRUCTIONIORILLING 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 /> State Laws, and Rules and Regulations of the San Joaquin County. Home owner or licensed agent's signature certifies she. following: "I <br /> certify that in the performance of the work for which this permit is issued, I shall not employ persons subject to WOR1OlAN'S COMPENSATION <br /> Laws of California." Contractor's hiring or sub-contractingemployersonsature subject toifies the WORKMAN'Sfollowing: 11 1 certify that in the COMPENSATION Laws of California.,$ THEAPPICANT <br /> of the work for which this permit is issued, I salt employ pe <br /> MUST CALL 24 OU S i ADVANCE FOR ALL REQUIR <br /> E <br /> D UtSAECTIO+NS AT(2091468-3423. Complete drawing at lower area provided. Date <br /> ` <br /> -�� acf i-c� p�.►:�1sw Title r/E g�.� <br /> S i gned <br /> FJ i <br /> DEPARTMENT USE ONLY <br /> Date Area" <br /> Application Accepted By <br /> Date Pump Inspection By Date <br /> Grout Inspection By <br /> nate Comments- <br /> Destruction Inspection BY �* <br /> ACCOUNTING DMLY: AID# FAC# rI�I <br /> PE CODES FEE INFO AMOUNT REMITTED CBEWICASH RECEIVED BY DATE PERMITISERVICE REIII INVOICE <br /> I � 1 <br />