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CATION fOR WELLIPVMP PERMIT <br /> APPLI <br /> �JOACIUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH 01VISION <br /> P a 60X 368, 446 N. SAN JOACIUIN ST., STOCKTON, CA 96201.388 <br /> (2081 458-3420 <br /> NOM-BEfiJNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ,JUN 2. 3 <br /> This application is <br /> a or install the k described. pp <br /> Application is here by made to the San Joaquin ctcpme fora permit to construct nd/ t�'�IZ ��_. „-b is Health <br /> made in compliance with San Joaquin County Deve!cpment Title, Chapter 9-1175.3 and the standards <br /> tH,r!`!_� <br /> services, Environmental Health Division. PERMfT/SERVICES <br /> Job Address/or APM# 1 r city ��� Parcel Size/APB# ff i <br /> S N[[I !( �• if VYI� _ Address �►^t� Phone # Yl <br /> Address 210 <br /> Owner's Name • f <br /> #70-7-37q <br /> Contractor Address Y Lic#L <br /> Sub Cantrector A I til,[` 6dir Address�}l 1 2'`A„ ` , &1fes*`'" A L i c# Phone # <br /> TYPE OF WELL PUMP: 0 NEW WELL [7 REPLACEMENT WELL (1 MONITORING WELL # (] OTHER <br /> C7 DESTRUCTION C] OUT-OF-SERVICE WELL Il GEOPHYSICAL WELL * ` SOIL BORING <br /> 11 INSTALLATION [] WELL SYSTEM REPAIR [1 CROSS=CONHECT REPAIR C] VAPOR EXTRACTION WELL # <br /> , <br /> [7 New 0 Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL--_ I <br /> (TYPE OF PUMP) . <br /> INTENDED USE TYPE--DF CONSTRUCTION SPECIFICATIONSt <br /> (1 INDUSTRIAL :C3 OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING <br /> (] DOMESTIC/PRIVATE [7 GRAVEL PACK/SIZE <br /> TYPE OF CASING/STEEL/PVC <br /> DIA. OF WELL CASING <br /> p PUSLIC/MUNICIPAL [] DRIVEN DEPTH OF GROUT SEAL Q—T'b SPECIFICATION <br /> OTHER GROUT SEAL INSTALLED BY "vK GROUT GRAND NAME <br /> (7 IRRIGATION/AG [] f <br /> [] MONITORING GROUT SEAL PUMPED: � Yes Cl Na CONCRETE PEDESTAL BY DRILLER: C] Yes No ` <br /> APPROIL DEPTH 30/ LOCKING CHESTER BOX/STOVE PIPE L <br /> PROPOSED CONSTRUCTIONIDRILLING METHOD: MUD ROTARY_ AIR ROTARY,-•_ AUGER CABLE_ OTHER_ <br /> the work will in <br /> I hereby certify that 1 have <br /> Regulationsrthis <br /> the San Jaion n d County.that <br /> Home owner or c�ensede in aagent'S signatureccordance with ncertifiesCthe tfollowing-. "I <br /> State Laws, and Rules andrsons subject to WORKMAN'S COMPENSATION <br /> certify that in the performance of the work for which this permit is issued, I shall not employ pe10 1 certify that in <br /> Laws of California." Contractor's hiring or sub-contracting <br /> signature rsons sub ect toifies the WORKMAN'SfCOMPENSATION Laws of California-"the THEAPPLCANT .j <br /> of the work f r which this permit is issued, I s:-all employ pe J <br /> MUST CALL 24 DU S INrVA9tCJ FOR ALL REQUIRED U SPECTIONS AT 12091 x•3473- Ctimplet drawing atxer .area provided. /�j�� ; <br /> L( /� L•^l.t;4.►�c-.�� I>'M104" Title �•L'✓ Date [1-�jS i <br /> Signed X <br /> Ii <br /> r <br /> DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted ey <br /> Date_ PSP Inspection By Date <br /> Grout Inspection By <br /> Conments• <br /> Destruction inspection SyDate----�--- A7 f` I <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECIIOCASH RECEI ED BY GATE PERMITISERVICE REQUEST NUMBER INVOICE ' <br /> Z9bl S � � g to od <br />