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APPLICATION FOR WELLIPUMP PERMIT y <br /> \-�N JOAQUIN COUNTY PUBLIC HEALTH SEhVICe,--._J <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 389, 445 N. SAN JOADUIN ST., STOCXTON, CA 96201-388 <br /> (209) 488-3420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (CompMu is 1 <br /> Application is here by made to the San Joaquin C.7unty for a permit to construct and/or install the work described. This application is <br /> made in compliance with San Joaquin County Deyel:pment Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br /> Services, Environmental Health Division. e,� <br /> Job Address/or APN# 3 yyo e cT iayJi5iQ� S <br /> A) City -70CI-7 01-) Parcel Size/APN# <br /> owner's Name UGTiQA Address 52-5-4). 3---Jc/•• //.NF..cO, CA Phone # / <br /> Contractorf fiPi�O-J Ew✓ 40%Ae"Er�t IiVC Address-SO)/ (,pepjgZaTiyiu./QtCanN,Svl�Lic#y � Phone <br /> Sub Contractor oO11 CJ4E4Z- CO*f^ Address PO, -deV �=J/AAw/+0 cDQDk0lic# 4¢ Phone 06114 <br /> TYPE OF WELL/PUMP: NEW WELL [3dE'GCENENT WELL )6� MONITORING WELL # ❑ OTHER <br /> U DESTRUCTION Q OUT-OF-SERVICE WELL U GEOPHYSICAL WELL # SOIL BORING <br /> [3 INSTALLATION Q WELL SYSTEM REPAIR p CROSS-CONNECT REPAIR VAPOR EXTRACTION WELL # / <br /> ❑ New p Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL —80' <br /> (TYPE OF PUMP; <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> (J INDUSTRIAL (] OPEN BOTTOM DIA. OF WELL EXCAVATION �_ DIA. OF CONDUCTOR CASING <br /> (I DOMESTIC/PRIVATE til(GRAVEL PACK/SIZEit-2- TYPE OF CASING/STEEL/PVC /loth OIA. OF WELL CASING <br /> U PUBLIC/MUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL %i3EQ •i✓fl_ SPECIFICATION Z*yr-cA"*ii, Y N1 • <br /> IRRIGATION/AG IZ OTHER GROUT SEAL INSTALLED BY 44,14c6et GROUT BRAND NAME Al <br /> *MONITORING GROUT SEAL PUMPED:A Yes &No CONCRETE PEDESTAL 8Y DRILLER: [I Yes�1(f No <br /> APPROX.DEPTH Rb - 40 / LOCKING CHESTER BOX/STOVE PIPE A-V <br /> PROPOSED CONSTRUCTIONIDRILLING 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, 111 <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 CCMPEHSATION <br /> Laws of California." Contractor's hiring or subcontracting signature certifies the following: " I certify that in the performance <br /> of the work for which this permit is issued, I stall employ persons subject to WORKMAN'S COMPENSATION Laws of California." THE APPLICANT <br /> )RUST CALL 24 HO S IN ADVANCE FOR ALL REDUIRED PECTIONS AT(2091468-3423. Complete drawing at lower area provided. <br /> Si ned X Title P�v�6r pt /r/1 /'• Date 23- <br /> 9 <br /> VCU <br /> DEPARTMENT USE ONLY <br /> ­60 <br /> Application Accepted By Date Area <br /> Grout Inspection By Date Pump Inspection 8y A Date <br /> Destruction Inspection By Date Comments:-&07-014 <br /> ACCOUNTING ONLY: AID# FAC# <br /> I <br /> PE CODES FEE INFO AMOUNT REMITTED CHECXIICASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br />