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~- APPLICATION FOR WELLJPUMP PERMIT <br /> JOAQUIN COUNTY PUBLIC HEALTH SERVICESO <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOAQUIN ST, STOCKTON, CA 36201.388 <br /> (2091468-3420 <br /> NON-REFUNDABLE PERMIT EMRES 1 YEAR FROM DATE ISSUED <br /> (Cohn in Triplimtel <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 Development Title, Chapter 4-1115.3 and the Standards of San Joaquin County Public Health <br /> Services, Environmental Health Division. J 'I o <br /> Job Address/or APN# - AI i�2 S AAl'o) E(r1�/ rl city <br /> �Da� -lll Cy Parcel Size/APWk a �� lQ! <br /> Cjc¢t i Z P J2c7 F ��� Address C(>�,c D 5 ffphone C� F <br /> Owner's Name — <br /> Contractor �.�-� Address 2� Lic# �f/L2f� __� Phone <br /> Sub Contractor Address Lic* Phone A <br /> TYPE OF -LL/PUMP: Q NEW WELL Q REPLACEMENT WELL � MONITORING CELL �M �! (IOTHER <br /> [I DESTRUCTION Q OUT-OF-SERVICE WELL [3GEOPHY5ICAL WELL it _ L3 501E BORING <br /> ❑ INSTALLATION (I WELL SYSTEM REPAIR [3 CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL <br /> [] New Q Repair H„P- DEPTH PUMP SET F.T. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFFCATIONS <br /> 1] INDUSTRIAL E] OPEN BOTTOM DiA. OF WELL EXCAVATION / DIA. OF CONDUCTOR CASING <br /> i/ <br /> I3 DOMESTIC/PRIVATE Q GRAVEL PACK/SIZE TYPE OF CASING/STEE P C DIA. OF WELL CASING <br /> ❑ pUBL1CfMUNIC[PAL Q DRIVEN DEPTH OF GROUT SEAL I- L SPECIFICATION <br /> [I IRRIGATIONlAG [I OTHER GROAT SEAL INSTALLED BY GROUT BRAND NAME <br /> MONITORING GROUT SEAL PUMPED: (I Yes No CONCRETE PEDESTAL BY DRILLER: ❑ Yes -Irmo 'ham <br /> APPROX.DEPTH LOCKING CHESTER BOX' fOVE PIPE <br /> PROPOSED CONSTRUCTIONIORILLING METHOD: MUO ROTARY! AIR ROTARY{ AUGER CABLE_ OTHER_ <br /> I hereby certify that I have prepared this application and that .he 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 the fallowing: "1 <br /> certify that in the performance of the work for which this permit is issued. I shaLL not employ persons subject to,WORKMAN'S COMPENSATION <br /> Laws of California.” Contractor's hiring or sub-contracting signature certifies the foilowing: " I certify that in the performance <br /> or the vork for which this permit is issued, I si�aLL empLay persons subject to k+ORKMAN'S COMPENSATION Laws of California." THE APPLICANT <br /> MUST CALL 24 HOURS ADVANCE FOR ALL REQUIRED INSPECTIONS AT (209)486.3423. Complexe drawing at Lower area provided. <br /> C <br /> Signed x e� GQ ]L TitLef6� L! � Date/� a?19<f <br /> DEPARTMENT USE ONLY <br /> Application Accepted Sy Dom, Area <br /> Grout Inspection By <br /> Date( Z� P In 4 '' - flare lL <br /> Destruction Inspection By Date Comments: <br /> ACCOUNTING ONLY- AID* FAC* <br /> PE CODES FEE INFO AMOUNT REMITTED CHEMVCASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> ?-�a ,��/ ` *0122L- z s D DSS' <br />