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APPUCATIdN FOR WEWPUMP PERMIT <br /> SAKE 1DAWIN COUM PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> IL P 0 8OX 331, 445 K. SAN JDAHUIN ST„ STOCKTON. CA 9SZ0f.3e8 <br /> 17.09) 488.3420 <br /> 101-REi:UNOABL!PERMIT EXPIRE! 1 YEAR FROM 2M 14SUEo <br /> r AppLication is here by made to the San Joaquin Cxawty for ; permit to construct <br /> arWor the made in comptiance with San Joaquin County Devetopoant Titte, Chapter 9-ms.3 and the att Sttandards of San Jrk oequii CaPubtlictHa tth <br /> Services, EnvirormentaL HeaLth Division. ounry Job Address/or APNg 0 GnS Gty% C� Yee City L <br /> Parcet <br /> ._ S2 waa+ Ttt S vee 93�3p/APk <br /> Name t�% <br /> {� <br /> Owner's NaIA C Address <br /> Phare <br /> Contractor Address �L o a H P B <br /> O i �{Lf�YkW, <br /> ��1 7 <br /> Sub Contractor t Vv Il Address � pX,5714 �LOVc4C <br /> Lich O Phone ItZ4�- <br /> TYPE OF aELL/PUMP- NEY WELL 0LACEHEN7 WELL ��MONLTORIHG WELL i�� ' q OTHER <br /> [3 DESTRUCTION CI CUT•OF-SERVICE WELL E3 GEOPHYSICAL WELL SOILr BORING O1 <br /> !3 INSTALLATION 13 WELL SYSTEM REPAIR p CROSS-CONNECT REPAIR C3 VAPOR EXTRACTION WELL aL <br /> (TYPE OF PUMP) 13 Now L7 Repair H.P. UMP DEPTH PSET FT. FIRST WATER LEVEL <br /> INTENDED USE TYPE OF WELL CONSTRUCnag SP FICATiONS ` ` <br /> 12 INDUSTRIAL (3 OPEN BOTTOM DIA. OF WELL EXCAVATION ti— Wk DIA. OF CONDUCTOR CASING /�+ <br /> [I DOMESTIC/PRIVATE � GRAVEL PA=/SIZE � TYPE OF CASINWSTEEL/PVC V C DIA. OF YELL CASING a rr A <br /> 4 <br /> Cl PUBLIC/MUNICIPAL (3 DRIVEN DEPTH OF GROUT SEAI.TO QC �--�► SPECIFICATION ro-Sack C ew1eV4T <br /> LI IRRIGATION/AG 13 OTHER GROUT SEAL INSTALLED BY_3Z2tkt&V GROUT BRA NAM <br /> xMONITORING GROUT SEAL KIkPED: Yes {3 No ,, jt CONCRETE PEDESTAL BY DRILLER: (I Yes go <br /> 10PROX. DEPTH LOCKING CHESTER BOX/STOVE PIPE N <br /> OPOSED CDNSTRUCTIONIDRILWIG 1[kTHOD: MWAOTAJIT AIR ROTARY` ALMERX,,- CABLES-_ OTHER„` <br /> I hereby certify that I have prepared this &MLlcacion and that the work will be dans in aeeordancs with San Joaquin County Ordinances, <br /> State lams, and Rutes and Reyutations 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 N PLey persons subloct to•YORIaANIS CCNPENSATION <br /> Laws of Catifornim.0 Contractor's hiring or sub-contracting signature certifiesthe fotlowing: e I certify that in the performance <br /> a, thr aark for vhich this permit is issued, I shall employ persons subject to WORKMAN'S COMPENSATION Laws of California." THE APPLICANT <br /> MUST CALL 24 HOURS IN ADVANCE FOR ALLREDt! EO L><.SAECTLONS AT 12081488.3429. Comptete drawing at Lower area provided. <br /> Signed X ✓ V>F 11 � a <br /> TitLa @ IS'i�ve Geo[o I Date <br /> S a C- P L- q. M T AlC s-1 D <br /> aEPAgINIFIiT USE ONLY <br /> Application Accepted By /7�� <br /> Date ! Area��(l <br /> Grout Inspection By Data <br /> �^. Puop Inspection By Date Q <br /> Destruction Inspection By Datetv sf/✓�/ <br /> .,.�` Coomerwts: <br /> L <br /> CCOUNTING ONLY: AID# FA <br /> PE CODES FEE INFO AMGUNT REMMED CHEWCASH RECEIVED YY DATE PEIf WISESVa imauEsEsT NUMBER INVOICE <br /> • <br />