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APPLICATION FOR WELLIPUMP PERMIT <br /> JOADUIN COUNTY PUBLIC HEALTH SERVICE <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOAOUIN ST., STOCKTON, CA 95201.368 <br /> (209) 468.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUED <br /> (ComPloto in TFiplkBtol C SHW DESCRIBED. HIS APPLICATION IN <br /> COMPLIANCE WITH SAN <br /> APPLICATION IS HERE BY MADE TO THE NSTALL TH <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHHAPTER 9-1115.3 AND THE STANDARDS O AN JOAQUIN CJOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR IOUNTY PUBLIEALTTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> so n . �Jinc�0.L ( QVe CITY �')�on PgRCEL SIZVAPNI <br /> JOB ADDRESS/OR APNI <br /> m 2l e l 111 4 (OW'C�I� ADDRESS �JIS.Wye— PHONE♦ <br /> OWNER'S NAME �i <br /> CONTRACTOR �l\�T� `TC�C7 SS_ �U_Yh�OS ADDRESSLu'Yy�O)•J UC15�O��J� PFI0NEE7�.� ZO�{[J <br /> ADDRESS UCS PHONEM <br /> SUBCONTRACTOR <br /> ❑ <br /> TYPE OF WELVPUMP: NEW WELL ❑ RERIICEMENT WELL ❑ MONITORINGWELL/ OTHER J <br /> ❑ INSTALLATION Cl WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL M O <br /> ❑Naw❑Raub H.P. <br /> DEPTH RIMP SET___FT. FIRST WATER LEVL <br /> (TYPE OF PUMP) ❑ OUT-0FSERVICE WELL ❑ GEOPHYSICAL WELL t ❑ SOIL BORING B <br /> -}�(P <br /> ,1[JDESTRUCTION: I AtP' de-p' 11 <br /> INTENDED UbE TYPE OF WELL CONSTRUCTION SPECIRCATONB <br /> DIA.OF CONWELL CASING <br /> CASING D <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL E%CAVATION O <br /> TYPE OF CASING/STEEL/PVC DIA. I F WELL LASING <br /> ❑ DOMESTIClPRIVATE ❑GRAVEL PACK/512E R <br /> DEPTH OF GROUT SEAL SPECIFICATION <br /> ❑ RIBUC/NIRRIGATIONIAGPAL ❑DRIVEN f <br /> GROUT SEAL INSTALLED SY GROIR BRAND NAME <br /> Cl MONITORING <br /> OTHER CODRETE PEDESTAL BY DRILLER:❑Ys [IN. S <br /> ❑ MONRORING GROUT SEAL PUMPED: ❑Vs ❑Ne <br /> S <br /> LOCKING GREETER BOX/STOVE RPE- <br /> APPROX.DEPTH OTHER <br /> PROPOSE])CONSTRUCTION/DROWNO METHOD: MUD ROTARY AIR ROTARY <br /> AUGER CABLE <br /> I HEREBY CERTIFY THAT 1 HAVE PREPAAED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCOIIDANCE WRM SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:•I CERTIFY THAT IN THE R:RFORMANCE OF THE WORK FOR WHICH <br /> THIS PERIMR IS ISSUED.I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMpE16ATION LAWS OF CAUFORNIA.• CONTRACTOR'S HIRING OR SU"ONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: E CERTIFY THAT IN THE PERFORNS SUE o[TT WORC A 'R OH TH..M.w Ie ISSUED.1 SHALL EMPLOY PERSONS SUWER TO WORIDAAN'Y COMP SATON LAWS F <br /> .... .... ..... �{/ '.. <br /> ... .... ... ... .... C \... .... .. .. .. .. ... .,.... :.......... 0... . <br /> ... .. .... .... ..... ................... ...... •... <br /> DEPARTMENT USE ONLY <br /> APpllutlpn AccepuC By Dsta Arae <br /> Grout Impmtlon By Dua Rupp Impa:tlon By Date <br /> Datructlon Impaction By / / Data �;;Z IIl r, 1 n <br /> 1 <br /> ACCOUNTING ONLY: AIDS FgCM <br /> PE CODES FEE INFO AMOUNT RQAITTED ECWCASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUNBM INVOICE <br /> (IC' �(3 S <br />