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INTENDED USE <br />0 INDUSTRIAL <br />DOMESTIC/PRIVATE <br />0 PUBLIC/MUNICIPAL <br />0 IRRIGATION/AG <br />0 MONITORING <br />APPROX. DEPTH <br />TYPE OF WELL <br />OPEN BOTTOM <br />0 GRAVEL PACK/SIZE <br />0 DRIVEN <br />0 OTHER <br />- <br />PROPOSED CONSTRUCTIONIDRILLING METHOD: MUD <br />ACCOUNTING ONLY: AID# FAC/t <br />PE CODES <br />, <br />FEE INFO <br />1410 -1 <br />AMOUNT REMITTED RECEIVED BY <br />o 7-5 /') <br />WELL NON•REFUNCIABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />10•111111.0111.PINNOMI <br />Application <br />is here by made to the San Joaquin C.,..rity for a permit to construct and/or install the work described. This application is <br />made in compliance with San Joaquin County Develcpuent Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br />Services, Environmental Health Division. <br />Job Address/or APN# i j 1 d c-/IA CityS..r / Parcel Size/APN# <br />(, -, <br />Owner's Name •Tee- /4.,LI:::ii * re06e5- Address <br /> 1 <br />'-/Cii_S 5 <br />L- eZt. Pe-. c,/,,c, <br />Contractor Vi t4,1 A- , thi4-ei AddressAic 57 /Z)/4- 1 ,-.. 14 Lic# CV 7(S , <br />Sub Contractor tc- '(i, /if -e,i,' Yior',•/,,viti., 1c44 Address it it I Y ?Pi SI 5.64, .....“ ir Licit , 1., , <br />I I 4 <br />TYPE OF WELL/PUMP: 1] NEW WELL <br />DESTRUCTION <br />0 INSTALLATION <br />0 New 0 Repair <br />(TYPE OF PUMP) <br />0 REPLACEMENT WELL 0 MONITORING WELL # 0 OTHER <br />(] OUT-OF-SERVICE WELL (] GEOPHYSICAL WELL * „le, SOIL BORING <br />(] WLL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR El VAPOR EXTRACTION WELL # <br />H.P. DEPTH PUIIP SET FT. FIRST WATER LEVEL C> <br />CR <br />-C. <br />SA <br />Al <br />APPLICATION FOR 7TLLIPUMP PtRrmi <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />0 BOX 388, 446 N. SAN JOAQUIN ST, STOCKTON, CA 962E11-388 <br />(209) 468-3420 <br />Phone # <br />Phone # 7c -.3 )4 — 2 c1/5 <br />Phone # ri/Z 7-7 l"_35 <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING <br />TYPE OF CASING/STEEL/PVC DIA. OF WELL CASING — <br />DEPTH OF GROUT SEAL -S',1-61 /Ic y" SPECIFICATION <br />GROUT SEAL INSTALLED BY /11404%) <br />GROUT BRAND NAME <br />GROUT SEAL PUMPED: t,(4, Yes 0 No CONCRETE PEDESTAL BY DRILLER: 0 Yes g No <br />LOCKING CHESTER BOX/STOVE PIPE <br />ROTA.R.Y AIR ROTARY AUGER CABLE OTHER <br />I <br />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 licensed agent's signature certifies the following: "I <br />certify that in the performance of the work for 4lich this permit is issued, I shall not efrploy 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 />of the work for which this permit is issued, I shall employ persons subject to WORKMAN'S COMPENSATION Laws of California." <br />THE APPLICANT <br />MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12091 468.3423. Complete drawing af lower area provided. <br />Signed X - <br />Tit e ° e( <br />DEPARTMENT USE ONLY <br />Date <br /> ) <br />Area <br />Application Accepted By <br />Oat P spection By Date <br />Grout Inspection By <br />Destruction Inspection By Date <br />Date/( i45 <br />DATE PERMITISE ST-1111111fETT--11ffliff— <br />/ <br />1 <br />r.32 7 c y3