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' APPl1CA716N FOR WELUPUMP PERMIT .I <br /> SAN JOAQUIN CQUNTY PUBLIC HEALTH SERVICES �• <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O SOX 381L 446 N. SAN JOAQUIN ST., STOCXTON, CA 96201-398 <br /> 12091 4118-3420 j•`�— <br /> y : <br /> XON•R6FINDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED _t � <br /> .. �r , <br /> Application is here by made to the San Joaquin Cvnty for a permit to construct and/or install the,wp�k described. This application is <br /> made in compliance with San Joaquin County DevelcpDent Title, Chapter 91115.3 and the Standards egiw ?Qp �s�{�q +t Public Health <br /> services, Environmental Health Division. L LL PERMIT/SERVICE�H <br /> Job Address/or APR#_ 1 r City Sr�GI�IJP Parcel Size/APN# <br /> Owner's Name Address Phone <br /> u} ,r Address Li.01, ��7�1� Phone #�a-7 7y-2AIS <br /> Contractor. <br /> Sub Contractor <br /> YtAddress M f �Zia� .� J0�[irt. `t Lic# Phone # X16 _LJrZ-79�9 f <br /> , <br /> TYPE OF VEIL PUMP: ❑ NEW WELL (3 REPLACEMENT WELL r p MONITORING WELL # 13 OTHER <br /> _ ❑ DESTRUCTION p OUT-OF-SERVICE WELL p GEOPHYSICAL WELL k SOIL BORING <br /> p INSTALLATION I3 WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR p VAPOR EXTRACTION WELL N <br /> ❑ New ❑ Repair H.P. DEPTH PULP SET F.T. k. FIRST-VATER LEVEL <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFTCATIONS � ! <br /> DIA. OF WELL EXCAVATION DlA. OF CONDUCTOR CASING <br /> - <br /> I] INDUSTRIAL 11 OPEN BOTTOM <br /> I] DOMESTIC/PRIVATE p GRAVEL PAC7C/SIZE <br /> TYPE OF CASING/STEEL/PYC ` DIA. OF WELL CASING r <br /> q PUBLIC/MUNICIPAL [3 DRIVEN DEPTH OF GROUT SEAL -TD SPECIFICATION <br /> 4� <br /> {] IRRIGATION/AG p OTHERGRGUT SEAL INSTALLED BY ��i•w�_. GROUT BRAND NAME ��'• <br /> GROJT SEAL PUMPED: Yes p No CONCRETE PEDESTAL BY DRILLER: p Yes No <br /> Q }MONITORING ' <br /> APPROX.DEPTH • r 3 oLOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED C°NSTBUCTIGN1GRli11NG METHOD: <br /> ROTARY_ AIR ROTARY_ AUGER CABLE, OTHER <br /> ccordance with <br /> Joaquin <br /> I hereby certify <br /> Rules and Reprepa ed OfthepticatiOn lan loaguin Countythat thHome owner e work wiLL ar ticenone sedaagent's signature ncertifies Cthe.following E"I <br /> State Laws, rsans sublect t° WORIOMAN'S CCMPENSATION <br /> certify that in the performance of the work for which this permit is issued, E shall not emplaY persons <br /> t certify that in the performance <br /> Laws of California-° Contractor's hiring or sits-contracting signature certifies the fo{lowing: of Cati <br /> of the work f r which this permit is issued, I shaLl employ persons subject toWORKMAN'S ing at provided. THEAPpl1CA1ET <br /> MUST CALL 24 GUS IN �AYANC FOR ALL REGUTAEEi II15?ECTIONS AT 1209) 3423• C°"'p Date �Js <br /> yb2V-%4z ti Title <br /> Signed x 1144 <br /> IV I <br /> J L <br /> DEPARTMENT USE ONLY C <br /> Dace0- Area <br /> Application Accepted BY <br /> Grout Inspection By Date pump inspection By r Date <br /> Destruction Inspection Sy Date Comments: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE lRFO AMOUNT REMITTED CHECXJ7CASH RECID ED BY DATE PEAi11TISERVICE REGUEST NUMBER INVOICE <br /> S �otie 00 ; <br />