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PPUCATION FOR WELLAMP PERMIT -- �- <br /> SA. JOAQUIN COUNTY PUBLIC HEALTH SERVICES l i1 4� j <br /> ENVIRONMENTAL HEALTH DIVISION sPP�� <br /> P 0 BOX 388, 445 N, SAN JOAQUIN ST, STOCXTON, CA 95201.388 <br /> (209) Ull-=O 'r r-HE2 qqr <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED _NV���iI�iMEN!r GAL'IH <br /> (Cm*lets in Tripfwul <br /> A,r,licatioi is here by made to the San Joaquin Canty for a permit to construct and/or install the workdes�><jL` T:1r1+bs a PubctHealts <br /> rv. l.'Sln <br /> .e in compliance with San Joaquin County Deveent Title, Chapter 9-1115.3 and the Standards of San Joaquin County <br /> services, Environmental Health Division. <br /> J-,b Address/or APN# ]2(� E � City = t`I Parcel Size/APN# <br /> �,�Ly liCtiGl <br /> Address �Cn t f�I�Zr1 S CA Phone 5-/,/ i 710 4 <br /> Owner'su' �,lic Yoyl <br /> -9697/ <br /> "itractor <br /> ( x1 �N�AI Cc"�I,A,n4 Address`ls,C cl{ 4kQA A �� Licit a�i �7 Flo Phone # 9ilu 3(-7/-cz <br /> nn /� cy>'�-� Lic* `f '-7t3� Phone # cfIlo 7-11 C2ZZ <br /> ij Contractor Address(o�?� �JYfu i^ I�CQ <br /> 't"PE OF YELL/PUMP: (3 NEW WELL [] RE'IACEMENT WELL MONITORING WELL # I) R CJ OTHER <br /> X DESTRUCTION Cl OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL # Cl SOIL BORING A _ <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR C] CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL <br /> ❑ New ❑ Repair N.P. DEPTH PUMP SET FT. FIRST WATER LEVEL V <br /> JYPE OF PUMP) (� <br /> NTENOED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING <br /> ;J INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WELL CASING V <br /> ❑ DOMESTIC/PRIVATE ❑ GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC <br /> DEPTH OF GROUT SEAL �i - 0 SPECIFICATION <br /> fa PUBLIC/MUNICIPAL ❑ DRIVEN <br /> ;] IRRIGATION/AG ❑ OTHER GROUT SEAL INSTALLED BY '-I'Vc.✓�'%�e- GROUT BRAND NAME 1�o r�"I�-�-n� V\ <br /> a� GROUT SEAL PUMPED: Yes U No CONCRETE PEDESTAL BY DRILLER: C] Yes .ya Na <br /> Cl MONITORING <br /> r <br /> APPROX. DEPTH `I�: LOCKING CHESTER BOX/STOVE PIPE_ __ 1 <br /> PROPOSED CCNSTRUCTIONIDRILUNG METHOD: MUD ROTA;Y_ AIR ROTARY_ AUGER_ CABLE_ OTHERXC VLgW r <br /> hereby certify that I have prepared this apolication and that the work will be done in accordance with San Joaquin County Orainances, <br /> irate Laws, and Rules and Regulations of the San Joaquin County. Hone owner or licensed agent'spersons tun subject certifies <br /> theS`COl1PENSATIO, (1 <br /> ertify that in the performance of the work for which this permit n issued, I shall not employ pe <br /> taws of California." Contractor's hiring or sib-contractiD9rsons subjecttoure to�WORKHANfies eSfCOMPENSATION Laws of California.11 THE APPoLLowing: 11 1 certify that in the L CANT <br /> of the work for which :his permit is issued, I shall employ <br /> MUST CAL OURS VANCE REQUIRED UtSPECTIONSS AT (2,09) 488.3423. Complete draw' love are�aa provided. <br /> Title Date�Jo <br /> igned X <br /> DEPARTMENT USE ONLY <br /> kVDate 2 Area <br /> Application Accepted 3y <br /> Grout Inspection By <br /> Date Pump Inspection By Date <br /> ;Destruction Inspection By <br /> Date Comments: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHEC7(PCASH RECEIVED BY DATE PERMITISERVICE REDUEST NUMBER INVOICE <br />