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--- - - - —' APPLICATION FOR WELLIPOMP PERMIT <br /> s JOADUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 SOX 36a, 446 N. SAN JOADUIN ST, STOCXTON, CA 96201.388 <br /> (209) 468-3420 <br /> NON.REFUNDABLE PERMIT MIRES71 YEAB FROM DATE ISSUED i; r•,1 <br /> Application is here by made to the San Joaquin Canty for a permit to construct and/or instal[ the work described. This application is <br /> made in compliance with San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br /> Services, Environmental Health Division r S IZA--�1Parcel Size/APN# 09 2,-/P" .0 <br /> 3`131 �L <br /> Job Address/or APN# city <br /> 0. bG`F �� -3 S`A'C-K Phone # <br /> �l l l e-s I ruckI V, Address 1� L <br /> Owner's Name l s S <br /> IiL•t44✓ <br /> IL <br /> ##%IE <br /> IDI-1 C Phone <br /> F AddreSBContractorU � IS Lic# Lphone <br /> sub Contractor Address �D� SI <br /> � <br /> T WELL y( MDNITDP.ING WELL # [7 OTHER ,� <br /> TYPE OF WELL/PUMP_ NEN WELL [] RE''LACEM.EHIrl' SOIL BORING '� <br /> ' [] DESTRUCTION (] 01T-OF-SERVICE WELL [7 GEOPHYSICAL WELL # f-' <br /> INSTALLATION (] WELL SYSTEM REPAIR [7 CROSSCONNECT REPAIR FT. FIRSTPOR NATERTLEVEL��WELL # <br /> [7 New C] Repair H.P. <br /> DEPTH PUMP SET <br /> (TYPE OF <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS II <br /> OIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING <br /> [7 INDUSTRIAL [] OPEN BOTTOM TYPE OF CASING/STEEL/PVC DIA. OF WELL CASING <br /> [] OCMEST IC/PRIVATE [7 GRAVEL PACK/SIZE__ _ <br /> DEPTH OF GROUT SEAL rt,A r'(x,ce -k' 1A SPECIFICATION <br /> [] PUBLIC/MUNICIPAL [7 DRIVEN GRCUT SEAL INSTALLED BY GROUT BRAND NAME �Lr�1buw <br /> [] IRRIGATION/AG [] OTHER GROUT SEAL PUMPED: -A Yes [] No CONCRETE PEDESTAL BY DRILLER: [] Yes 13 No <br /> [7 MONITORING ` SI <br /> APPROX.DEPTH UU�.�— LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTRUCTIONIORILLING METHOD: MUD ROTARY_ AIR ROTARY AUGER CABLE__ OTHER_ <br /> I hereby certify that [ have prepared this application and that the work will Da done in accordance with San Joaquin Cthe f Ordinances, <br /> rsons subject to WORKMAN'S COMPENSATION <br /> Sm Joaquin County. Hare owner or ls <br /> certify that in the performance of the work for which this peicensed agent's signature certifi <br /> State laws, and Rules and Regulations of the Ses Che. following: <br /> rmit is issued, I shall not employ Pe „ 1 certify that in the performance <br /> Laws of California." Contractor's hiring or sub-contracting signature certifies the following: <br /> of the work for which this permit is issued, I shall employ per subject to WORKMAN'S COMPENSATION Laws of California." THEAPPLICANT <br /> MUST CALL 24 NpS/N AOYAI/�CE FUR LL REDUIRFD INSPECTIONS AT (2091463-3423 <br /> Complete drawing at lower (area rovided. <br /> �/ (LN 7 (L/ Title �ieslG�e Dale_ <br /> Signed % <br /> DEPARTMENT USE ONLY AUGOaCe 11 Area <br /> Application Accepted BY Date <br /> Date Pump Inspection By - - <br /> Grout Inspection By <br /> DateCamlents• <br /> Destruction Inspection 0y <br /> # <br /> ACCOUNTINGAID# IAC <br /> PE CODES FEE INFO AMOUNT REMITTED IICASH RECEIVED BY DATE PEAMITI��� EST NUMBER INVOICE <br /> _ r � <br />