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APPLICATION FOR WEWPIIMP PERMIT <br /> nN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388. 445 N. SAN JOAILUiRI ST., STOCKTON, CA 95201.388 <br /> 091468-3420 <br /> MGM REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> IBsWMMRWM§PEiI <br /> Application is here by inside to the San Joaquin Canty for a permit to construct end/or install the work described. This application is <br /> made in coWLlartee with San JoeSdn County Oc"Lcpnent Title, Chapter 9-1115.3 and the Standards of San Joaquin County Publle Reslth <br /> Services, Environmental Health Division. 0 4 Z- 'OU-01 <br /> job Address/or APNN '�C1 3 lyiw--tati1 city Parcel Size/APNA <br /> lI/es ��� Addressr-0-8)c f}3o3 f7a/ kjZoB Phone 4y8-6268 <br /> Owner's Nage 37y-26/J <br /> tancraetor_ ,Lj�r v / Address L[cM Phone # Z7 <br /> Pill" — <br /> sub contractor tiWS r` �Nu,rox Aear.as �yX $'Oo 2'- N 9SzL�'Liet M '772-3620 <br /> ,� OF VELL/PUMP: 19 NEW WELL ❑ REPLACEMENT WELL M MONITORING WELL # E1 OTHER ' <br /> (I DESTRUCTION 0 DUT•OF•SERVICE WELL I] GEOPHYSICAL WELL # '*SOIL BORING <br /> [1 INSTALLATION 17 WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR O VAPOR EXTRACTION WELLIII— <br /> 0 New a Rapair N.P. DEPTH PUMP SET FT. FIRST WATER LEVEL — <br /> (TYPE OF PUMPI <br /> INTENDED USE TVP£DF WEU CONSTRUCTION SPECIFICATIONS e <br /> ❑ INDUSTRIAL ❑ OPEN BOTTOM ,I DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING <br /> DIA. OF WELL CASING , <br /> ❑ DOMESTIC/PRIVATE jE GRAVEL PACK/9I2E TYPE OF CASING/STEELS' SPECIFICATION_ /:-- <br /> ❑ PUBLIC/MUNICIPAL [JDRIVEN DEPTH OF GROUT SEAL <br /> ❑ IRRIGATION/AG ❑ OTHER <br /> GROUT SEAL INSTALLED BY Tre-.vn",t- GROAT BRAND NAME l�bv <br /> .(d <br /> MONITORING GROUT SEAL PUMPED: ' Yes ❑ No CONCRETE PEDESTAL 8Y DRILLER: T1 Yes � No <br /> C_ <br /> APPROX. DEPTH GiU LOCKING [NESTER 80X/STOVE PIPE 6t1-1211L CX- <br /> PROPaSEO CONSTRUCTIONIBRILLIND METHOD: MUD ROTbTT_ AIR ROTARY__ ALICECABLE_ OTHER__ <br /> I hereby eeKify that I hexa prepared this appl Section and that the work will be dune in accordance with San Joaquin County Ordinances, <br /> State Laws, and Rules and Regulations of the San Joaquin Courcy. Heave! owner or licensed atoy persons subject tonature �fWORKMAN'S i es the fCOMPENoit SATION <br /> certify that in the performance of the work for which this permit is issued, 1 shall not oL loY pa <br /> Laws of California." Contractor's hiring or suln-cuntraeting signature certifies the tot laNfry: " I certify that in the performance <br /> of the Work for which this permit is issued, [ $.all sRplay Per Subject to WORKMAN'S COMPENSATION Laws of California-" THE APPLICANT <br /> MUST CALL la H RS ADVAyCE F�ALL NEOUIRED EISPECTIONS AT ROSI 4W3423. CoWtete d <br /> I,"J, � <br /> rowing at lower'srea provided./ <br /> +J/) (/�/X(/it , YGSr�Qu r� Date <br /> signed XTitle_ A _ <br /> ri <br /> DEPARTMENT USE ONLY <br /> Onto Area <br /> Application Accepted 8y <br /> �( I- x{77 <br /> Date paW Inspection By - _ Date <br /> Grow[ Inspection BY <br /> Destruction Inspection By <br /> Date COUm ts: <br /> ACCOUNTING ONLY: AID# FACN <br /> PE CODES FEE INFU AMOUNT REMITTED CIECKP SH RECgIVED BX DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> q. 00 13q 1711 , <br />