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'APPLICATION FOR WELL/PUMP PERMI'r <br />SAS )AQUIN COUNTY PUBLIC HEALTH SEi 'ES eo5�-•-2-o <br />ENVIRONMENTAL HEALTH DIVISION <br />304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br />(209) 468-3420 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete in Trinlicets) <br />APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />JOAOUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1 115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SFRVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR APN# 2-c7-r•'.�1Z�L/►1�:�: <br />PARCEL SIZE/AFMR <br />,S !'� CITY✓ tr^ <br />rAC# <br />ER' <br />OWNS NAME 14 01-1,41-P/1,s : (,•5 <br />C t� <br />AODRESS ZyU L�S_ I PHONE .F- <br />CONTRACTOR e.,i'lxcK L,/!. !'a / 41..v' inc �t7 <br />/��, ADDRESS .!% ,j f� c i -7 <br />�A 7,: 5S"O�i;�y-% cr 7/GDi'P MI ONEIlb�):37y_y�,(t� <br />DATE <br />PERMIT/SERVICE REGUEST NUMBER INVOICE <br />SUB CONTRACTOR_ <br />ADDRESS LIC# F 4ONF. 9 <br />TYPE OF WELL/PUMP: <br />❑ NEW WELL ❑ RFPLACEMFNT WELL MONrTORINO WELL # ❑ OTHER <br />❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS -CONNECT REPAIR ❑ VAPOR EXTRACTION WELL # <br />11Naw ElR—i, H.P. <br />__ <br />DEPTH PUMP SET FT. FIRST WATER LEVEL J <br />O <br />(TYPE OF PUMP) <br />�q <br />❑ OUT -OF -SERVICE WFLL ❑ GEOPHYSICAL WELL # p/ SOIL BORING __ <br />g <br />❑ DESTRUCTION: <br />A <br />INTENDED USE <br />TYPE OF WELL <br />CONSTRUCTION SPECIFICATIONS <br />❑ INDUSTRIAL <br />❑ OPEN BOTTOM <br />GG .% <br />DIA. OF WELL EXCAVATION J DIA. OF CONDUCTOR CASINO <br />p <br />❑ DOMF9TIC/PnIVATE <br />® GRAVEL PACK/SIZE''g <br />TYPE OF CASING/STEFL/PVC -. c /I yO ry'(- DIA. OF WELL CASING <br />❑ PUBLIC/MUNICIPAL <br />1:1DRIVEN <br />DEPTH OF GROUT SEAL O -- SPECIFICATION 00;'e- <br />q <br />❑ IRRIGATION/AO <br />❑ OTHER <br />GROUT SEAL INSTALLED BY GROUT BRAND NAME /Y/9 <br />F <br />MONITORING <br />GROUT SEAL PUMPED: ® Ya. ❑ Ne CONCRETE PEDESTAL BY DRILLER: ❑ Yee ❑ No <br />S <br />APPROX. DEPTH <br />�OC> <br />LOCKING CHESTER BOX/STOVE PIPE_ <br />5 <br />PROPn AFO CONS TRUCT10 <br />NfM1.UNG METHOD: MUD ROTARY <br />AIR ROTARY AUGER_�O _ CABLF. OTHER <br />Apolle.tlon Aeoaptad <br />O—A I—Pa tj n By <br />v <br />OFPARTMENT USE ONLY <br />D.te P— In.peetian By <br />bats 1'1 Are. <br />D.ta Z t <br />ACCOUNTING ONLY: <br />AID# <br />rAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED CHECK#/CASH RECEIVED By <br />DATE <br />PERMIT/SERVICE REGUEST NUMBER INVOICE <br />Pub. Health Serv. - Enviro. 173 (1/97) <br />