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APPLICATION FOR WELLJPUMP PERMIT <br />JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 96201.388 <br />(209) 458-3420 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application is here by made to the San Joaquin Canty for a permit to construct and/or install the work described. This application is <br />made in compliance with San Joaquin County Develcpment Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br />Services, Environmental Health Division. <br />r <br />Job Address/or APN# B I �,� i"�`i Y L•v, hjL bl� Ci ty `> —1t C I t' Parcel Size/APN# <br />Owner's Name �" l l l l k IWv- (fit i v Address i ic 3 Phone ` -l3 <br />�1C 'IC rte. 3,i �� '1 IZ Lic.0 SJ ZG,s/� 2.r <br />Contractor _S� \ IS I ►'k,'� tvvrL� Address � I �` �t tp Phone # �� �" �yS J� 2— <br />Sub <br />Sub Contractor�� �G rr 4v tiwi�' V�ln+<a.�clAddress �� 11 S -I Lic# Phone # <br />TYPE OF WELL/PUMP: Ig NEW WELL <br />(I RE?LACEMENT WELL <br />MONITORING WELL # ` <br />C] OTHER <br />[3 DESTRUCTION <br />C] OUT -OF -SERVICE WELL <br />[] GEOPHYSICAL WELL # <br />❑ SOIL BORING <br />[] INSTALLATION <br />❑ New [] Repair <br />Q WELL SYSTEM REPAIR <br />H.P. <br />[] CROSS -CONNECT REPAIR <br />DEPTH PUMP SET FT. <br />C] VAPOR EXTRACTION WELL # <br />FIRST WATER LEVEL ± -3C <br />(TYPE OF PUMP) <br />215 <br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS N <br />[] INDUSTRIAL [] OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING <br />[] DOMESTIC/PRIVATE P( GRAVEL PACK/SIZE '�1 TYPE OF CASING/STEEL/PVC 51( t -r '/C' DIA. OF WELL CASING y t <br />[] PUBLIC/MUNICIPAL [] DRIVEN <br />DEPTH OF GROUT SEAL t Z T�' SPECIFICATION • �, C ✓-t Z <br />C] IRRIGATION/AG [] OTHER GROUT SEAL INSTALLED BY f t�/�[ lh­(-GROUT BRAND NAME fl;. t/`' "'I <br />MONITORING GROUT SEAL PUMPED: ❑ Yes V No CONCRETE PEDESTAL BY DRILLER: ;K Yes (] No <br />Y <br />APPROX. DEPTH N LOCKING CHESTER BOX/STOVE PIPE w ti e- � ,— - <br />PROPOSED CORSTRUCTIONIDRILLING METHOD: MUD ROTARY_ AIR ROTARY_ AUGER x 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 Ordinance , <br />State Laws, and Rules and Regulations of the San Joaquin County. Home owner or licensed agent's signature certifies the following: <br />certify that in the performance of the work for which this permit is issued, I shall not employ persons subject to WORKMAN'S COMPENSATION <br />Laws of California." Contractor's hiring or sub -contracting signature certifies the following: " I certify that in the performance <br />or the work for which this permit is issued, I s`.alL employ persons subject to WORKMAN'S COMPENSATION Laws of California." THE APPLICANT <br />MUST CALL 24 URS I$ ADVANCE FOR ALL REQUIRED IRSPECTIONS AT (2091488-3423. Complete drawing at Lower area provided. <br />(. -i-TW. Title ✓.'lc�� ���c- Date <br />Signed X iL' ��_ <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />Dat <br />DEPARTMENT USE ONLY -- - <br />VP Date Area <br />Date Pump Inspection By Date <br />e Comments: ,'w <br />ACCOUNTING ONLY: <br />AID# <br />FAC# <br />CHECX CASH RECEI ED BY <br />DATE <br />PERMITISERVI INVOICE <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />p <br />215 <br />S <br />S►� oosoo <br />- <br />� <br />l <br />