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�' — — -- APPLICATION FOR WELL/POMP PERMIT <br /> JOAOUIN COUNTY PUBLIC HEALTH SERVICt�..ir <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOAQUIN ST.. STOCXTON, CA 96201-388 <br /> (209) 468-3420 <br /> ' NON•REr'UNOABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete ie'�) <br /> Application is here by made to the San Joaquin Cr,ty for a permit to construct and/or install the work described. This application is <br /> -m <br /> made in compliance with San Joaquin County Devel:pment Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br /> Services, Envirormentat He <br /> a <br /> lth Division. �^ -,c G <br /> Job Address/or APN# "7 � ��a,Aly ' C/i Cy /L��„ i�� Parcel Si ie/APN# <br /> Owner's NamerC>'/y1�r Address Sly �/ irc�tSl` �o 6/"rte+ « Phone # q <br /> Contractor '++' .20.d/�yI/�%YJ�1>ti�✓T4 Address�SO�/ rza l.J/ ' ic#/ /2 Phone <br /> Sub Contr ,'vim Address/.�l�fA�.�.��3�1 o a Lic# tP �a�/ / Phone # lAJFiS'Z Z. S- <br /> TYPE OF YELL/PUMP: NEW WELL 0 2E?'-ACEMENT WELL MONITORING WELL # C] OTHER <br /> U DESTRUCTION 0 OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL # C7 SOIL BORING <br /> 0 INSTALLATION 0 WE''L SYSTEM REPAIR 0 CROSS-CONNECT REPAIR C7 VAPOR EXTRACTION WELL # <br /> [7 New 0 Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE WCONSTRUCTION SPECIFICATIONS % <br /> 0 INDUSTRIAL [']1 OPEN BOTTOM DIA. OF WELL EXCAVATION (5 � DIA. OF CONDUCTOR CASING <br /> 0 DCMESTIC/PRIVATE [H GRAVEL PACK/SIZ -J TYPE OF CASING/STE=_L/PVC_f�U . / DIA. OF WELL CASING <br /> SPECI <br /> ICATION & <br /> (] PUBLIC/MUNICIPAL [7 OTHER DEPTH OF GROUT SEAL INSTALLED BY C//'. ��rr•� GROUTFBRAND NAME^tri <br /> 'C'7f IRRIGATION/ O <br /> y/J MONITORING GROUT SEAL PUMPED: X Yes ❑ No A' CONCRETE PEDESTAL BY DRILLER: 0 Yes �No <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE P PE IV� <br /> PROPOSED CONSTRUCTIONIORILLING METHOD: MUD ROTARY_ AIR ROTARY_ AUG'cR CABLE_ OTHER__ <br /> 0 <br /> I hereby certify that I have prepared this apelication and that the work will be done in accordance with San Joaquin County Ordinances, <br /> State Laws, and Rules and Regutations 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 .rich this permit is issued, I shalt not employ persons subject to WORKMAN'S CCMPENSATION <br /> Laws of California." Contractor's hiring or s;a-contracting signature certifies the following: " I certify that in the performance <br /> o" 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 OURS IN ADVANC fOR ALL AEffUIRED UIS?ECTIONS AT 1209)4E8.3423. Complete drawing at <br /> Lower area provided. <br /> Title <br /> VCtii�o �'Gi t°l� �i�C.-Date l7�i6 <br /> Signed X CN v <br /> �y <br /> -- - <br /> DEPARTMENT USE ONLY (,mac <br /> Application Accepted 8y Date <br /> S- Are- <br /> Grout Inspection By Date Pump Inspection By Date <br /> Destruction Inspection By Date Comments: 0)'W/ <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED I CHECXlICASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> • D0 b0 <br /> I <br />