Laserfiche WebLink
APPLICATION FOR Y9tWrumr rchhecu <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERV <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 38114 440 N. SAN JOAQUIN ST., STOCKTON, CA 98201-388 <br /> (209) 488.3420 <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 18a�lI�N�la1 _ <br /> Application is here by made to the San Joaquin Canty for a permit to construct and/or- install the k described. This application is <br /> made in compliance with San Joaquin County Develcpment Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br /> Services, Environmental Health Division. <br /> Job <br /> Job Address/or APN# 393 1 1"`^�{"� WJ City Parcel Size/APN# 092-/P `0-1 <br /> owner's Name6TIL1l BS Tit,itCkINAddress T'0- 130`8 P503 5'1-VC<-70 Phone # 9*t oda <br /> ho Contractor-Iii �YYuGlhei� fk0Jl✓I ti4,k,si, Address JDIJ Z61 � Taytd — LIco Phone #916``t43- / <br /> Sub Contractor V W �l�IL11" Address �DX S1 �1�- 'IIS j� Licit �SB��� Phone # <br /> it TYPE OF WELL/PUMP: NEW WELL U REPLACEMENT WELL MONITORING WELL # D OTHER ? <br /> D DESTRUCTION D OJT-OF-SERVICE WELL D GEOPHYSICAL WELL # `4 SOIL BORING J <br /> D INSTALLATION D WELL SYSTEM REPAIR [I CROSS-CONNECT REPAIR D VAPOR EXTRACTION WELL #_ <br /> D New D Repair X.P. DEPTH PUMP SET FT. FIRST WATER LEVEL Si <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �t <br /> D INDUSTRIAL D OPEN BOTTOM DIA. OF WELL EXCAVATION g DIA. OF CONDUCTOR CASING <br /> D DOMESTIC/PRIVATE D GRAVEL PACK/SIZE__ TYPE OF CASING/STEEL/PVL DIA. OF WELL CASING <br /> D PUBLIC/MUNICIPAL D DRIVEN DEPTH OF GROUT SEAL Sttrft,. -ID Tb SPECIFICATION <br /> D IRRIGATION/AG D OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME PUr'I1dM <br /> D MONITORING / I GROUT SEAL PUMPED: 'I Yes D No CONCRETE PEDESTAL BY DRILLER: D Yes D Nt <br /> APPROX.DEPTH 6s LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTRUCTIONIORILUND METHOD: HUD ROTARY_ AIR ROTARY_ AUGER CABLE_ OTHER_ <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, <br /> State Laws, and Rules and Regulations of the San Joaquin County. Home owner or licensed agent's signature certifies the. following: "1 <br /> certify that in the performance of the work for Which this permit is issued, I shall not employ persons subject to WORKMAN'S CCMPENSATIOI <br /> Laws of California." Contractor's hiring or sib-contracting signature certifies the following: " 1 certify that In the performance <br /> of the work for which this permit Is issued, I shall employ persons subject to WORKMAN'S COMPENSATION Laws of California." THEAPPLICANI <br /> MUST CALL 24 HpURS AOYA CEFF RR LL REDUIREO INSPECTIONS AT 12091488-3423. Complete drawing a�(t-�lower area0 Red. <br /> Signed X_ I �' �� "�0`t"�� Title l <�l Date 212,J <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Aree <br /> h <br /> Grout Inspection By Date Pimp Inspection By Date <br /> Destruction Inspection By Date Comments: <br /> ACCOUNTING ONLY: AID# I FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECXflCASH RECEIVED BY DATE PERMITISERVICE REQUEST NOMBER INVOICE <br />