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APPLICATION FOR WELLIPUMP PERMIT — <br /> JOAQUIN COUNTY PUBLIC HEALTH SERVICE <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 80X 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201-380 <br /> (209) 400.3420 <br /> NOW-REFUNDA6lE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICamplatm in Trfp{kata) <br /> 4PPUCATION 18 HERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANWOR INSTALL THE WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPUANCE WITH SAG <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER B•111 6.3 AND THE b'Tr4l OF BAN J AOUIN COUNTY1_PUBLIC HEALTH SERVICES,ENVRIONMENTAL HEALTH DIVISION. <br /> l\ �CITY PARCEL BIZEIAPN/ <br /> JOB ADDRESS/ORAPN! \ `N"v'Nl'— n 1 C �/�-- L ,/�''��,��l777 t� / �r`C <br /> �J.V� 11�.�♦ ��\�5., i. ���`MMitS\I.ADDRE68 '�,�� I�d Z_P� 1�1 C"1' Pt10NE/ `-1 G.�1��C�S <br /> UWNER'9 NAME 1' � �� -� ��f <br /> -- ��CvtiGrl� rC\O�l� S <br /> � �` ��v'`��\Y� ADDRESS O� ICI _PI40NE M C2_ <br /> CONTRACTOR � <br /> r �j _ <br /> ICS] i'^ I��CJ <br /> 1� ��T� ADDRESS n PtiONEI <br /> SUB CONTRACTOR ^+-�-��-� rlS� <br /> S�p T r <br /> TYPE OF WEGLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL/ ❑ OTItER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR Cl CMS8-CONNECT PFPAIR ❑ VAPOR EXTMCTION WELL! J <br /> ❑Nw+❑Ropalr N.P. <br /> DEPTH PUMP SET FT, FIRST WATER LEVEL <br /> (TYPE OF PUMP) 9 <br /> ❑ OUT-0FBERVICE WELL ❑ GEOPHYSICAL WELL! BOIL DOIMNG <br /> ❑DESTRUCTION: ,,,, <br /> A <br /> INTENDED U&Q F W CO.aTAUC TION aPECIfiC ATION& /I <br /> DIA.OO WELL EXCAVATION DIA.OF CONDUCTOR CA81N0 /v A D <br /> ❑ INDUSTRIAL Cl OPEN BOTTOM r—AT <br /> TYPE OF CASING(STC EEL/PVDi A.OF WELL CASING lu O <br /> ❑ DOMESTICIPNVATE ❑GRAVEL PACK/SIZE T�� <br /> ❑ PUBUCMMNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL_ �Crt�1 t(A C)tiS SFFCIFICATION R <br /> ®OTHER ,YirY1� �+�Q GROUT SEAL INSTALLED BY 1�/' �I�;' GROUT BRAVO NAME <br /> ❑ IRAIOA ATION/A `l <br /> GROUT SEAL PUMPED: f9 Yaa ❑Na CONCRETE PEDESTAL SY DPNLLER:❑Ye. F-114- <br /> r7lMONITORING S <br /> I LOCKING CHESTER BOX/STOVE PIPE S <br /> APPROX.DEFT. () ' 1 / <br /> PROPO/ED CON&TAUCTTONfMLUm0 METHOD: MUD ROTARY AIR ROTARY AUGER LADLE OTHER I�'PL �SG� <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY OrliNNANCES,STATE LAWS,AND 1101-114"1 <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFOMIA14CE OF THE WORK FOn WHIC <br /> THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'&COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HINNG OR SUB CONTRACTING P.iONATUPT CERTIFIE <br /> THE FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WOnK FOR WHICH THIS PERMIT IS ISSUED,1&HALL EMPLOY FERSONS SUSJFCT TO WOlVWAN'6 COMFEHRATION LAW7 O <br /> CAUFORNIA.' UT <br /> ANT M CAALL�ZQ4/�{p U"IN ADVANCE FOUM <br /> IL ALL REGIED INSMTWN&AOT 12061 4"-142!. COMPLETE DRAWING AT LOWER AREA MVVIIDED. / <br /> SI nod X YL,G.C�_ Tltlo �,�C-.J (Ll D.ta <br /> a <br /> ,pp _ <br /> 11 — <br /> / I DEPARTMENT USE ONLY <br /> Applloatlon Aoi,"By CcY Dale <br /> Grout Iropeotlon BY Date Pump Iropeatlon By Date <br /> Deatruotlon Iropootlon BY Data <br /> Commanla: <br /> air P1�-Q <br /> ACCOUNTING ONLY: AID/ FAC! <br /> PE CODES FEE INFO AMOUNT RPAITTED CNE 60-AAH RECEIVED SY DATE PUMT/80MCE 11101.1117 NIAM051 IIYVOICIt <br /> m <br />