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- — — PPLICATION FOR WELUPUMP PERMIT <br /> SH OAQUIN COUNTy PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388. 446 N. SAN JO A0� 3N , STOCXTON, CA 96201.388 <br /> I <br /> NON•REPINDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> IBM is <br /> for a permit to construct and/or install the work described. This application <br /> Application is here by made to the San Joaquin O`"n'y Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br /> made in compliance with San Joaquin County Develcpaent Title, <br /> Services, Environmental Health Division. �,�[%� Parcel Size/APN# 6�2--I go- 09 city _ / �1 <l 7 77— <br /> Jab Address/°r APN# �� � ' � lx L /'c;5 � /[,�, F�;,,,,./ro Phone #�— <br /> T Address tISU� C{ L q(b-223-y/ <br /> Owner's Name OI �lU�r �+. ��u7O. Lic# Phone # <br /> f,t �wCtvt ka+ Address I�-7 - 37 Z�.LS <br /> Contractor V -tv Address 'CSU - <br /> lis �` - Lic# t�' _ Phone # 1 <br /> sub Contractor <br /> .�y OTHER <br /> ❑ REpLACEMENT WELL P MONITORING WELL # c <br /> TYPE O NEW WELL C] SOIL BORING <br /> [] OUT-OF-SERVICE WELL [] GEOPHYSICAL WELL # <br /> [7 DESTRUCTION [] VAPOR EXTRACTION <br /> S�WELL <br /> [] INSTALLATION (] WELL SYSTEM REPAIR CT DEPTH OPUMP O REPAIR SETFT FIRST WATER LEVEL_.. <br /> (] New [I Repair H.P. <br /> (TYPE OF <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> S,j DIA. OF CONDUCTOR CASING <br /> WELL EXCAVATIONS , <br /> C] INDUSTRIAL [1 OPEN BOTTOM <br /> DIA. OF -- � <br /> [] DOMESTIC/PRIVATE [3 GRAVEL PACK/SIZE__ TYPE OF CASING/STEEL/PVC /� y��L DIA. OF WELL CASING _, <br /> SPECIFICATION 60� ^`YG <br /> DEPTH OF GROUT SEAL A2� <br /> �a/ 4 <br /> (] PUBLIC/MUNICIPAL (] DRIVEN GROUT BRAND NAME <br /> ,_�.-- <br /> [] IRRIGATION/AG C] OTHER GROUT SEAL INSTALLED BYCONCRETE PEDESTAL BY DRI LLER:>S Yes 11 No <br /> GROUT SEAL PUMPED: Yes [] No I <br /> (] MONITORING G � 5{ovfl pine — <br /> 0� LOCKING CHESTER BOX/STOVE PIPE <br /> APPROX.DEPTH—� CABLE_ OTHER__ <br /> PROPOSED CONSTRUCTIONIORILLING METHOD: MUD ROTARY_ AIR ROTARY__ AUGER <br /> m County. Home owner or licensed agent's sena subject e certifies <br /> the'Sfoollowing: OM <br /> ( hereby certify tha[ ( have prepared [his application on and that the work will be done in accordance with son Joaquin County Ordinances, <br /> State Laws, and Rules and ReguLations of the son Joaqu not �� ( certify that in the performance <br /> certify that in the performance of the work for <br /> b-contractiih this ng nsignatureacertifiesl the fowl lowing: <br /> Laws of California." Contractors hiring ` persons subject to WORKMAN' COMPENSATION Laws of California." THE APPLICANT / <br /> of the cork f r which this permit is issued, f s..all employ Pa / /wC/4(p <br /> MUST CALL 24 OUI ,IN ADV}yN��FOR ALL REQUIRED INSPECTIONS AT 1209)4883423. ComQlete drawi ng '�h/wse Lower pr v�d -- Date` r <br /> `�_ (`b <br /> �. L <br /> Signed X <br /> DEPARTMENT USE ONLY <br /> Date d l Area <br /> �_ <br /> Application Accepted By Date <br /> Date Pump inspection By <br /> Grout Inspection BY <br /> Date Coaments• <br /> Destruction Inspection By <br /> FAL# <br /> ACCOUNTING ON <br /> ns <br /> ONLY: <br /> PERMITISERVICF R�UEST NUMBER <br /> PE CODES FEE INFO AMOUNT REMITTED CH ASH RECEIVED BY DATE INVOICE <br /> � Sbl <br />