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APPUCATION FOR WELLJPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION { :_1• <br /> P 0 SOX 388, 445 N. SAN JOAQUIN ST., STOCXTON, CA 96201.388 <br /> (2091 468-3420 <br /> NON.RIFUNDABLE PERMR EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Cmpka in Tri'ikaa) <br /> Utt3'.b � <br /> .oalication is here by made to the San Joaquin Canty for a permit to construct and/or install the cork describssf. 'caLion is <br /> tide in compliance with San Joaquin County Develocment Title, Chapter 9-1115.3 and the Standards of San Joagd'iiWPPl'i <br /> C"t*!-P(iblC�Health <br /> >er,ices, Environmental Health Division. <br /> ITMn � � T <br /> .ob Address/or APN# � C� T'Gt� 77M G n1tC City IrZALy Parcel Size/APN# <br /> lwnerIs N..auTTIEYW 4i-JiC, IMyt5 AddresznQ�Q�^�v�k�ILyy �I w S). GA ?I/'CrS Phone # `>/i5 S�j i7r,9 <br /> =on:.ractor INdu�h'i�� 4, '"i'\' Addresscj83E,vU i4kg A PJ Lic# 28 �.� ✓ Phone # 9/!p 36-9e97/ <br /> ,ub Contractor P\\ Tt v rk v,I I•-, - Address(vK�ydu-t^ Z-� Lic# <br /> 'YPE OF WELL/PUMP: S NEW WELL REPLACEMENT WELL MONITORING WELL # !I bR [] OTHER <br /> [] DESTRUCTION (] OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL # (] SOIL BORING <br /> INSTALLATION U WELL SYSTEM REPAIR (] CROSS-CONNECT REPAIR (] VAPOR EXTRACTION WELL # <br /> _ ❑ New ❑ Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> IMPENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS M <br /> (.I INDUSTRIAL [] OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING <br /> (] DOMESTIC/PRIVATE X GRAVEL PACK/SIZE ZG/­5" TYPE OF CASING/STEEL/ V Dir(✓. DIA. OF WELL CASING `+. <br /> PUBLIC/MUNICIPAL ❑ DRIVEN y� J DEPTH OF GROUT SEAL G q�. SPECIFICATION <br /> (.i IRRIGATION/AG ❑ OTHER GROUT SEAL INSTALLED BY +remit GROUT BRAND NAME pOr+LGc- ANZ <br /> ,<-R,JNITORING GROUT SEAL PUMPED: (d Yes (] No CONCRETE PEDESTAL BY DRILLER: (IYes 9 Noto <br /> r?ROX. DEPTH lir �S LOCKING CHESTER BOX/STOVEPIPE (' 5+ PCK <br /> OSED CONSTRUCTIONIDRILLING METHOD: MUD ROTARY_ AIR ROTARY AUGER X CABLE— OTHER— <br /> ,ereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, <br /> e Laws, and Rules and Regulations of the San Joaquin County. Home owner or licensed agent's signature certifies the following: "I <br /> zify that in the performance of the work for which this permit is issued, I shall not employ persons subject to WORKMAN'S COMPENSATION <br /> as of California." Contractor's hiring or stb-contracting signature certifies the following: 11I certify that in the performance <br /> ,ne work for which this permit is issued, I shall employ persons subject to WORKMAN'S COMPENSATION Laws of California." THE APPLICANT <br /> 'ST CALLURS IN-ADVANCE=FORREaUIRED I11SPECTIONS AT (209) 488.3423. Complete drawin at lower area provided.3ned X �5"r—" — — Title Ivyati7G� Da[e <br /> L Ll <br /> DEPARTMENT USE ONLY <br /> clication Accepted By Date Z / Area V' v <br /> ,'.--jut Inspection By Date Pump Inspection By/Q (� Date <br /> :estruction Inspection By Date Comments: Tf5 <br /> I ACCOUNTING ONLY: AID# FAC# _r <br /> PE CODES FEE INFO AMOUNT REMITTED CHECXAICASH RECEIV012 BY DATE PERMITISERVICE REOUEST NUMBER INVOICE <br /> I12 90 <br /> I <br /> 4 <br /> r <br />