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�IPPII&ATI&N FOR WELLIPUMP I'Ei3MIT -- <br /> SAA :OAaUIN COUNTY PUBLIC REALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> R 0 8ax 38$ 445 M. SAN JOA4UIN ST. STOCXTEIN. CA H5201-388 <br /> (2091 468.3420 <br /> U13WREo XCABLE PI:RMTT EXPIRES 1 YEAR FROM DATE ISSUE <br /> ICasn0etn in INPwI <br /> 4aolicatian is here by made to the San Joaquin •;>:rtty `or a permit to oonstrtset and/or install the work described. This application is j <br /> Wade in cort=liance with San Joaquin County DeY='-=finent Title, miapter 4-1115.3 and the Standards of San Joaquin County Public Health <br /> Services, Esiviranmental He <br /> a <br /> lth Division, 1 <br /> :aa Address/or APH# . 7Q ��S a"� Ciry �d C Td.y Parcai SizeJAPv# <br /> IL�Cl r Address ��LS� /h t�^�lS��/7d _ Phone <br /> :wner's Name / q <br /> .�ntrac <br /> for D`r'+zy u F1W1,fr4,, r1 r 7k/ Address D > ••� • i c3 Phone # ��% •7/�C� <br /> :ua C.:ntracto Lit# v7�/ Phone cS' <br /> "YP° OF DELL PUMP- NEW WELL ❑ L�S.�C-�4f?i7 WELL � MONITORING WELL R � E3OTHER <br /> r� <br /> X[3 DESTRuCrION (2W-CF-SERViCE WELL ❑ aaCPHYSICAL WELL $_ [3SOIL BORING <br /> ❑ INSTALLATION ❑ �-, SYSTc1 REPAIR Q CROSS-CONNECT RF-PAIR E1 VAPOR EXTRACTION 1W7:LL <br /> ❑ Nes+ (3 Repair H.P. OEPTH PUMP SE3 FT. FIRST WATER LEVEL �d <br /> "7PE OF PUMP) j <br /> NTEN ED USE TYPE GF WELL C311STRUCTION SPMFiCATIONS <br /> ] INDUSTRIAL ❑ OPEV 30T CM DiA. OF WELL EXCAVATION DEA. CF CONDUCTOR CASING <br /> r TYPE OF CASI7iG/STeEL/?VC U DIA. OF WELL CASING <br /> ;] OCME573C/PRIVATE: GRAVEL PAGA'JSTZ � � 7- / J — <br /> ?UBLTC/MlUNIOT PAL ❑ DRIVEN DEPTH OF GROUT SEAL/d Se r.4."�^� S?ECTFICATION_ CP J&Zr C CC/i/r+. � <br /> IRRIGl/MUN/AG ❑ DRIVETHER GROUT SEAL INSTALL0 BY�/`• C� GROUT BRAND NAME "Il <br /> : XMONITORING <br /> GROUT SEAL PUMPEDYes I3 No =NCRET'c PEDESTAL 3Y DRILLER: C2 Yes �No O <br /> 1/4X. OEpTN LGCxTHG CHE Sir1Z BOX/STOVE P PE <br /> ?ROPOSa CUNSTRUCTIDNIORILLING I/MOO: MUD ROTAAT ^ AIR ROTARY AUG'cZ CABLE_ OTHER— ' <br /> nereay certify that I have prepared this aocL;=tion ana :hat the work will De done in accar �nce with San Joaasin Cthe r Ordinances, ' <br /> State Laws, and Rules and Aegulations of the San Joaquin County. Hams owner or licensed agent's signature cert irics the following; "I <br /> :ar"fy that in the performance of the work far'#sich this Permit is issued, E shall not emtoy persons subject to-WORKMAN'S �IPERSAYION <br /> _aws of California." Contractor's hiring or sea-contracting signature certifies the following: ° T certify that in the performance <br /> or :ne toric <br /> or which this permit is issued, I s:.all emoioy persons subject to '4RKNAN'5 CCMP:NSATION Laws of California." THEAPPlICANT <br /> MUST CALL 24 CURS IN ADVANC FOR ALL REIIuIREII as?ECTIONS AT (2021 488.3423. Complete drawing at lower area provided. <br /> Signed X CN Title rtJr1a / p�/r2,re-Date��?G.� <br /> 1 1 1 1 1 1 k l I I I I I kIcy; <br /> V kA <br /> l k k 1 <br /> 111111111 11 , 1111 i � <br /> 11111111111111 11 III I <br /> OEPART1[81T USE CMLY <br /> �j� r <br /> Amiication Accepted By <br /> Date. Area <br /> Grout inspection By Oate Pump Inspection By if Date <br /> Zr- <br /> Destruction Inspection 3y Date Comments: Ol _ <br /> [AC=UNTlNr ONLY, � AID# FACS i <br /> PE CODES I F=c INFO 1 AMOUNT REUrTTE.D I CHEM11CASH I RECEIVED BY DATE PERNITISERVICZ REQUEST NUMBER I INVOICE <br /> ( rJ�6o <br /> I I I I I I I <br />