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APPLICATIOR FOR WEWPt MP PERMIT — — <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P 0 SOX 384. 446 4. SAN JOAQUIN ST., STOCKTON, CA 96201-388 <br />(209) 468.3420 <br />NON•R6i1NDA8LEP NET Pi S 1 ROM DATE ISSUD ORIGINAL. <br />I <br />Application is here by made to the San Joaquin CxritY for a permit to construct and/or instalt the work described. This application is <br />made in compLiance with San Joaquin County Devetepnent Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br />Services, Environmental Health Division. <br />GGD� ��� City v Parcel Size/APN# <br />Job Address/or A'P//N# D <br />Y(l��ell /'ld D� Address L �Gt�17� �iS t Phone # <br />pwner's Naax \ l �ZDiC7 Phone # 7�7 37�F-��L1 <br />(J v .(: vim- Address V l b Lie# <br />Contractor Z6 -�y2-3620 <br />Sub Contractor <br />Address L i cM� �_ Phone # <br />"P@ OF VELLINMP: � NEW WELL <br />U DESTRUCTION <br />CI INSTALLATIOW <br />13 News E3 R"m i r <br />(Type OF PIMP) <br />❑ RE'LACEMENT WELL <br />C2 CUT -OF -SERVICE WELL <br />p '.e L SY>TEM ReaArQ <br />H.P. <br />E) MONITORING WELL # <br />GEOPHYSICAL WELL <br />f1 CROSS -CONNECT REPAIR <br />DEPTH PUMP SET FT. <br />`Q� OTHER <br />E3 SOIL BORING ( / <br />El VAPOR EXTRACTION WELL # ' <br />FIRST WATER LEVEL <br />I T USE T� OE F WE f�ONSTRUCt14N SPEGif4CATf0i18 „ <br />DIA. OF WELL EXCAVATION DEA. OF CONDUCTOR CASING C 1 <br />C] IMOUSTRIAL [) OPEN BOTTOM S �d DIA. OF WELL CASING <br />2L <br />2` TYPE OF CASING/STEEL/ VC -� <br />l3 DCNESIIC/PRIVATE aR'i GRAVEL PACK/SIZE O � SPECIFICATION -� <br />11 PUBLIC/MU`NICIPAL E3 DRIVEN DEPTH OF GROUT SEAL <br />GROUT BRAND NAME <br />tiRCUT SEAL INSTALLED BY <br />C3 IRRIGATION/AG U OTHER CONCRETE PEDESTAL BY DRILLER: ❑ Yes 14 No <br />E3 MONITORING GROUT SEAL PUMPED: P% Yes 13 No / <br />APPROX. DEPTH <br />LOCKING CHESTER BOX/STOVE PIPE <. ,isl le Lbo C <br />PROPaSED CONSTRUCTIONIORILLING METHOD: MUD ROTARY_ AIR ROTARY_ AUGER CABLE_ OTHER,,. <br />I 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 Joaquin County. Home owner or licenser! a9ont� n� subject toture �fWORK-MAN'SfcomPENSATiON <br />certify that in the Performance of the work for which this permssignature issued, I shiesl no eftrto {na: " I certify that In the performance <br />Laws of California." Contractor's hiring or suatLetractin9 <br />of the work for which this permit is issued, I s`.all employ persons Subject to WORKMAN'S COMPENSATION taws of California." THE APPLICANT <br />/ <br />MUST CALL 24 JOURS 1N ADVANCE FUR LL REQUIRED L"pECTIONS AT 8011 488.3423. Comptete drawing at lower',e�rea provided. <br />Title Date � <br />Signed X <br />Application Accepted By. <br />Grout Inspection By - <br />Destruction Inspection By <br />ACCOUNTING ONLY: <br />PE CODES I FEE <br />DEPARTMENT USE ONLY <br />Date Pump Inspection <br />Date. Coaments: <br />AID# IFAC# <br />AMOUNT REMITTED I CHECIEJICASH I RECEIVED BY <br />• •�y <br />?/ Areel�- <br />Date <br />DATE { PERMITISERVICE REQUEST NUMBER <br />INVDICE <br />