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`"; - j.. -�s�,'�9".zx* r �lr- .:rte, :. »�g`.'�'*"` .."`✓�5��,�r�'�« ,ay;,y. ..�"` <br /> / II <br /> APPLICATION FOR WELLIPUMP PERMIT <br /> � } SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> V R ENVIRONMENTAL HEALTH DIVISION <br /> P 0 8 }X 388, 445 N. SAN JOAQUIN ST, STOCKTON, CA 95201-368 <br /> (209) 468.3420 <br /> NO <br /> #I•REFUMDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUER <br /> U ICompku in Triplicate) <br /> APPLICATION IS HERE BY ADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1'11 5.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. - <br /> JOB ADORESSlOR APNf CITY PARCEL S1ZElAPNt ti/ <br /> OWNER'S NAME / } ADDRESS ONE0I.SIO�].1 r <br /> CONTRACTOR 47/?7L �]o�La��.furl/�. SZ ZA (—tom_-ADDRESS V rEJC I GQ'71dlIiF'FIONEf��4S I <br /> -- <br /> SUB CONTRACTOR ADDRESS LIC# PHONE I <br /> TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL .r ❑ MONITORING WELL# © OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTIUACTION WELLK' J <br /> ❑Naw❑P.P w H.P. -' DEPTH RUMP SET FT. FI WATER LEVEL .. O <br /> {TYPE OF PUMP1 Q <br /> © OUT-0FSERVICEWELL <br /> 13 G�EO�R+YSICAL i`WELL A <br /> B <br /> !!!DESTRUCTION: 4 At-,,G) Mori ttt 7 <br /> INTENDED <br /> USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING Q <br /> ❑ DOMESTICIPRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEUPVC DIA.OF WELL CASING D <br /> ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITORING GROUT SEAL PUMPED: ❑Y. 13N. CONCRETE PEDESTAL BY wo, iER ❑Y. ❑No S <br /> APPROX.DEPTH LOI:yUN6 CHEBrE3t BOXfBTOVE HPE / 5 <br /> PROPOSED CONSTRUC710I/drWIO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER ' <br /> :i <br /> I IOMY CERTIFY THAT 1 HAVE PF19W 7 T1SS APPLICATWU AND THAT THE WORK MILL nE COW N ACCOIOAWCE WM SAN JOAMM A„OWrY 0011 ANICE8,STATE LAWS,AND RULES AHD <br /> R73nYLATMINS OP TIE LAIR JOAO4IN COOP4V MW OMOAIIR OR LICEOISED AOEM'S SMGATUM C9ffVWA THE POLLamo :I CERnFV THAT N THE 11PERPOMWACE OF THE WORK FOR WHICH <br /> TMS PMW 19 NWJM%1 MALL MW ghOLOY!lII11110M M1411=7T040AeiItWN'S Cd91111IL90101E tAIMS OF CAUPORISA."CONTRACTWO ISMIO OR SLJbCQHrRACr1MR SIWMTURE comms <br /> .' :TIS I�LiOMMISi ,1,CMLit*11 TII"MTI 0110,7110 VMK POR UInSDI VM PO •11101 L I DfWL IRMLaY F61np1i SUiIECT TO M WWW W'S COEEINMATIM LAWS OF <br /> TIS MSM!aELlapr alit asllow A AILLMIII oaw A1u 11LLLL�S�IrS A'O!IMq 4111111AMM'OOMPL IM D1IMEIMS AT L0VM AREA FIEONRDEO.'- - <br /> „e <br /> Iml <br /> j <br /> AIMf�tLtl���OMiIaIIp�IORMSFOIEb ,. <br /> . <br /> ar7T ' <br /> a.-,,., •ra- .e- a .i. _a-.»a. a.L+�w tea. ` - ,.?l^,T..: <br /> s�:• ...¢ <br /> - i .. <br /> ...... ° :..i .. .. Q � <br /> Q - .. .. <br /> - --.. -- - <br /> ti a .......:... :......... .'H4vJ.. 7 .... ..... . . - <br />