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js, _" .-tet j • --•---- -.. <br /> APPLICATION FOR WELLIPUMP PE,IMIT _ - --- <br /> *" SAN JOAQUIN COUNTY PUBLIC HEALTH(SERVIG <br /> ENVIRONMENTAL HEALTH DIVISii?N <br /> i P O SRX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA J6201-388 <br /> (209) 468.3420 <br /> I� <br /> NOW-REFUNDABLE PERMIT EXPIRES"i YEAR FROM DATE 1SSt1E0 <br /> (Complete is T:ipruata) ! <br /> Application is here by made to the San Joaquin County for a permit to construct and/or install the work described. This application is <br /> made in compliance with San Joaquin County Devetopment Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br /> Services, Environmental Health Division. <br /> Job Address/or APR# &.L1ZK_01A1S ddKtE City �.L. Parcel SizelAPl# <br /> Owner's Name G�.rJ' .► Address ' Phone <br /> .icContractor Address Phone <br /> 'Sm Contractor GSW "V Address ,r a e—,11 i�y' Lic# phone <br /> TYPE Of WELL/PUMP: [I NEW WELL E3 REPLACEMENT WELL ><MONITORING;EWELL [3 OTHER <br /> 11 DESTRUCTION I3 OUT-OF-SERVICE WELL El GEOPHYSICAL`• WELL.# EI SOIL BORING <br /> E3 INSTALLATION b WELL SYSTEI0I MPAI [I CROSSCONNECT REPAIR EI VAPOR EXTRACTION WELL IVJ <br /> [I New EI Repair H.P* DEPTH PUMP SET FT.. FIRST WATER LEVEL <br /> tTYPE OF P4>M4P) � " , <br /> INTENDED USE TYPE OF WELL CDIISTRUCTION SPECIFICATIONS 41, <br /> €I INDUSTRIAL 13 OPEN BOTTOM IIIA. OF WELL EXCAVATION + DTA. OF cONOIIC11 TOR CASINC_ 3 <br /> [I DOMESTIC/PRIVATE EI GRAVEL PACKjSIZE TYPE OF CASING/STEEL/PVC DIA. OF WELL CASING I <br /> El PUBLIC(MUNfCIPAL :i1 DRIVEN.: DEPTH OF GROUT SEAL j :SPECIFICATION1 <br /> €I IRRIGATION/AG (1 :OTHER GROUT SEAL INSTALLED BY GROUT BRAND HANE a <br /> yIRdNITORiNG / GROUT SEAL PUMPED: 13 Yes EI go i CONCRETE PEbESTAI`$Y DRILLER: €1 Yes EI N ,' <br /> APPROI€.DEPTH LOCKING>CHESTER BOXISTOVE PIP.E�` p <br /> PROPOSED coNSTAUCTIONIDRILLING METHOD: MUD ROTARY;,_AIR ROTARY— AUGER,w"' CABLE_ ;;, OTHER_ <br /> I hereby certify that F have prepared this application and that the work wilt be done inti accordance with San Joaquin County Ordinarw es <br /> R 4 <br /> State Laws, and Rules and Regulations of the San Joaquin County. Home owner or Cicensed:agent's signature certifies the fol.(owing. " t <br /> certify that in the performance of the work for which this permit is issued, i shalt not employ persons subject to WORKMAN+B COMREN".+ATIt11l I <br /> Laws of Californie." Contractor's hiring or sub-eontracting signature certifiest the following; Of I certify that in the performane <br /> of the work for.wh ch this permit is issued, I shall employ persons subject to VOR&AN'S COMPENSATION Laws of Catiforni:a.w THEAPPLICAlIV i <br /> MUST CALL 24 HOU ADVA f0 ALL REQUIRED NSPECTIONS At(202)400.3423. Comptete drawing at Lower area provided <br /> �r w- f Lfli i. <br /> S i gned..X /LI' Title. J't Ct.r..Gfi ..: :Date <br /> ,t <br /> DEPARTMENT USE ONLY. <br /> Apptitation Accept ptoat.e J 1 Area <br /> Grout 'Inspection ay: Date.... Pune Inspection 8y' 1 Date <br /> Destro dtion :Inspection 0y Date- Comments <br /> ACCOUNTING ONLY: AID# 40 <br /> PE CODES FEE INFO AMOUNT REMITTED CHECUICASH RECEIVED Bmf DATE ;. PERNITISERVICE REQUEST0,011111 INYDICE <br /> f <br />