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r <br /> APPL16AT10N FOR.WELLIPDMP PERMIT �' <br /> ` AX JOAOUIN COUNTY PUBLIC HEALTH SERVIC <br /> i <br /> ENVIRONMENTAL HEALTH DIVISION <br /> � ��� d� � ' <br /> P 0 813X 388. 446 NJSAN JOA4UIN SSTOCXTON, CA 95201.388 . <br /> g.. <br /> (209) 468-3T.,420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED MAY 2: 3 1995 <br /> (Complete is INP■IsM ��r�-� <br /> Application is here by made to the San Joaquin County for a permit to construct and/or install the w&N%69A r7h4&%IW44 tion is <br /> made in compliance with San'Joaquin County Development,jitle, Chapter 9-1115.3 and the Standards of SaPfiRW%l8ER ic'Health <br /> Services, Environmental Health Division. ,J <br /> Job Address/or APN# $ 7 d AIE City _l�i 4y Parcel Size/APH# <br /> Owner's Name Address t'0 F'ox DA";TA- eA q 5374 Phone # '-zi-836--4r7 <br /> Contractor -T•nu P (' 1 to C-r 5 �,&.5o C-_- Address Qb$bX r'l47 FeCE&JI L i c# AIA Phone <br /> j <br /> Sub Contractor LS Ex -rim) -Sq-ye— Address %& i ei Lic# 0;L-G96 Phone =7-]4S 1-4s <br /> r <br /> TYPE OF WELL PUMP: NEW WELL a REPLACEMENT WELL MONITORING WELL # 3 (3 OTHER <br /> DESTRUCTION 0 OUT-OF-SERVICE WELL [3 GEOPHYSICAL WELL # [3 SOIL BORING <br /> INSTALLATION [3 WELL SYSTEM REPAIR [];CROSS-CONNECT REPAIR C3 VAPOR EXTRACTION WELL # <br /> C3 New C3 Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �+ <br /> t. <br /> [3 INDUSTRIAL (3 OPEN BOTTOM DIA.:OF WELL EXCAVATION DIA. OF CONDUCTOR CASING ` <br /> [3 DOMESTIC/PRIVATE F- GRAVEL PACK/SIZE X Ib TYPE OF CASING/STEEL/PVC FI)C _ DEA. OF WELL CASING <br /> [3 PUBLIC/MUNICIPAL (3 DRIVEN DEPTH OF GROUT SEAL � 3 r SPECIFICATION <br /> ❑ IRRIGATION/AG [3 OTHER GROUT. SEAL INSTALLED BYF-S GROUT BRAND NAME�NGS7fFf4 <br /> 3 MONITORING n GROUT SEAL PUMPED:10 Yes [3 No CONCRETE. PEDESTAL BY DRILLER: CI Yes [1 No <br /> APP ROX.13EPTH_ ,ZO 7 LOCKING CHESTER-SOX/STOVE PIPE Ta E Ing <br /> PROPOSED CONSTRUCTIONIDRILLING METHOD: MW ROTARY AIR ROTARY— AUGER,&_ CABLE_ OTHER_ t <br /> 1 hereby certify that I 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 Joaquih 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 CCMPEHSATION <br /> Laws of California.' Contractor's hiring or sub-contracting signature certifies the following: " I 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." THEAPPLICANT <br /> MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED MSPECTIONS'AT 1202)499-3423. Complete drawing at lower area provided. <br /> Signed X Titled Date�ly'1`S . <br /> t <br /> " E <br /> • i <br /> 'i <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date '5'-2,31-`- Areai� <br /> H <br /> Grout Inspection 8y Date Pump Inspection By \ i)ate <br /> Destruction Inspection By Date .' Comments: — <br /> xs <br /> LY: <br /> ACCOUNTING ONAID# <br /> YFAC# <br /> PE CODESFEE INFO AMOUNT REMITTED -4HECII#ASH Rti&io SY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> eo <br />