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SAN JOADIIIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 446 N. SAN JOActum ST, STOCKTON,CA 96201-388 <br /> 0209) 468.3420 <br /> MON REFUNDABLE PERiRIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Me"Ists In Triprmts) <br /> Application is here by made to the San Joaquin County for a permit to construct and/or install the work described This application is <br />%made in compliance with San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br /> Services, Environmental Health Division. <br /> ' Joh Address/or APH# 12- 1 5 T"1 ��+ S� CiSTW.�:h2 ` Parcel Size/APN# <br /> Owner's Name G r d kdu.i" [ n t Address Lia lla S /7t-y X -].s 7,2 1 Phone # <br /> J 3` �fsr-9s�o <br /> Contractor 14W 5�'1 SL� ¢�e r,kAddress �� A� r L i c# Phone <br /> jj�� <br /> Sub Contractor ��✓ice/Gc'�s�1 _ Address 3 r Lic# 612-?—(4,y Phoria # Co 712— <br /> TYPE OF WELL PUMP- C) NEW WELL ❑ REPLACEMENT WELL MONITORING WELL # M w_ 7 I7 OTHER f <br /> [] DESTRUCTION O OUT-OF-SERVICE WELL El GEOPHYSICAL WELL # X SOIL BORING(0 7tD � <br /> [) INSTALLATION [I WELL SYSTEM REPAIR [] CROSS-CONNECT REPAIR [] VAPOR EXTRACTION YELL # <br /> [) New [I Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> f INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS L) <br /> IA- <br /> 13 INDUSTRIAL [I OPEN BOTTOM DIA OF WELL EXCAVATION gIl DIA OF CONDUCTOR CASING <br /> 0 DOMESTIC/PRIVATE '-p( GRAVEL PACK/SIZE TYPE OF CASIMG/STEEL/PVC P U G DIA OF WELL CASING Z jr <br /> [} PUBLIC/MUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL ! SPECIFICATION S 4A �pG L <br /> [] IRRIGATION/AG [] OTHER GROUT SEAL INSTALLED BY Lam' '� GROUT BRAND NAME N i12�_ _ <br /> MONITORING GROUT SEAL PUMPED- K Yes 11 No CONCRETE PEDESTAL BY DRILLER 0 Yes [} No <br /> APPROX DEPTH 5 <br /> I LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTRUCTIONIDRILLING METHOD MW 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 Now owner or licensed agent's signature certifies the following "I <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 /> of the which this permit is issued, I shalt employ persons subject to WORKMAN'S COMPENSATION Laws of California " THE APPLICANT <br /> MUST 24 Flo SIN ADVANCE FOR LL REOUI ED INSPECTIONS AT{208)4W3423. Complete drawing at lower area provided 61z�� <br /> Signed X r Title Date <br /> DEPAIRYE>Y'i USE ONLY c <br /> Application Accepted By Date_,?- 2-1 � Are. <br /> Grout Inspection By Date Pump Inspecction By Date <br /> Destruction inspection By Date Comments 53 $4 -'`,1 07 50-,--,)�7tu,� <br /> ACCOUNTING ONLY AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKOICASH RECEIVED BY DATE PERMiTiSERVICE REQUEST NUMBER INVOICE <br /> /o! <br /> Ivo l (�-�TT�v S� S'� <br />