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------------ <br /> APPLICATION FOR WELLIPUMP PERMIT - <br /> ,, 1N JOAQUIN COUNTY PUBLIC.4EALTH-sERVICES,.,, <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201.388 <br /> (209) 468.3420 <br /> 11011-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is here by made to the San Joaquin Canty for a permit to construct and/or install the work described. This application is <br /> made in compliance with San Joaquin County Develcpnent Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br /> Services, Environmental Health Division. 1 <br /> Job Address/or APN# 3440 E-L5+ AACity% a6ee7 City G L r-o Parcel Size/APN# <br /> T- 52S- wea+ 'r LI %v- S vee 93a3o <br /> Owner's Name u��Yc�tANAd -4- tAC Address 1-4e►v�-�ow-a . C4�%4� %-u1a Phone # <br /> ' 1 3 t I Go v, &11 <br /> cr�lln'� %1 �qv kw a.I { 7 <br /> Contractor t 6V%ZQv% ^��ny1t�/o�n1M@1A � Address DE I PoVd o t+t 1%s Lic# all Phone #'114-5]3�9-AJ-70 <br /> Sub Contractor �1 W )y%, 1,l V�Ct Address 1 •�. 47�X s�, �LO�tcYAy Lic# 7OZ� !�� Phone #-7a-7`� 4.MI5 <br /> TYPE OF WELL/PUMP: X NEW WELL U RE?LACEMENT WELL 4X MONITORING WELL # _ U OTHER <br /> U DESTRUCTION [3 OUT-OF-SERVICE WELL [3 GEOPHYSICAL WELL # A SOIL, BORING o"Z <br /> U INSTALLATION U WELL SYSTEM REPAIR U CROSS-CONNECT REPAIR [3 VAPOR EXTRACTION WELL # <br /> U New U Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> c� <br /> U INDUSTRIAL I3 OPEN BOTTOM DIA. OF WELL EXCAVATION Oft"' I�11 DIA. OF CONDUCTOR CASING N <br /> U DOMESTIC/PRIVATE -x GRAVEL PACK/SIZE#� TYPE OF CASING/STEEL/PVC Py C tt DIA. OF WELL CASING aft 4 �f <br /> U PUBLIC/MUNICIPAL Q DRIVEN DEPTH OF GROUT SEAL T6FJye'ttm' %vteesSPECIFICATION 3CLGIC Cy�eW e+"+ <br /> [3 IRRIGATION/AG [3 OTHER GROUT SEAL INSTALLED BY DY tMe� GROUT BRAND NAME N l A <br /> xMONITORING GROUT SEAL PUMPED: Yes ❑ No A 1 CONCRETE PEDESTAL BY DRILLER: [3 Yes �I No <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE 'y C /' <br /> PROPOSED CONSTRUCTIONIORILLING METHOD: HUD 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 the following: "I <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 following: 1' I certify that in the performance <br /> or the work for which this permit is issued, I stall employ persons subject to WORKMAN'S COMPENSATION Laws of California." THE APPLICANT <br /> MUST CALL 24 HOURS IN ADVANCE FOR ALL REDUI ED INSPECTIONS AT(209)488.3423. Complete drawing at lower area provided. <br /> Signed X Aq etA 4�0✓ OF VV Title r4Z415jreVed GeolDate_13117 <br /> S la T C- PL- PN IN CH- E' D <br /> DEPARTMENT USE ONLY 9 <br /> Application Accepted By Date ! f Ares <br /> Grout Inspection By Date Pump Inspection <br /> /Byy Q AD- - Date R/ <br /> Destruction Inspection By Date Comments:- %G�`� fP� �i O. f f�'� z �f�✓V <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECXTICASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br />