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+t✓ .— _ 7' APPLICATION FOR WELLIPUMP PERMIT ? } 1 <br /> U'JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />'i ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON. CA 98201.388 AUG <br /> (2091468-3420 <br /> i <br /> 04 M <br /> NDN•REFUNDABLE PERMIT EXPIRES 1 YEAR FROM GATE ISSUED <br /> Application is here by made to the San Joaquin Canty for a permit to'C'ofsstruct 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 NeaLth 1 <br /> Services, Environmental Health Division. \ Cl' F <br /> -I (a 16 ��•�- �t'+'Y'� S�Vee�'Ci tY r Parcel Size/APN# <br /> Job Address/or APN#� � 1 <br /> t,MtgAeUe A- 4&C S Address 12 to b n H OM Phone # 6lo -I'78�4800 <br /> Owner's Name sal o E 'Lt 1'av' W4 1435 <br /> 1111 '' 11 c Ca Lic# Phone Al 16 _aIZ� <br /> I Contractor {�OY1Z0N �V1�I 1NONvw�! Address _ p <br /> VDy, eX 5' . hLayl5taic# "7 0 �4 Phone # O <br /> Sub Contractor + A7�1 A LNa Address <br /> TYPE OF WELL/PUMP: I] NEW WELL l 0 REPLACEMENT WELL VMONITORING WELL # Mw- � <br /> tTHER C5ee SAe \ah) <br /> XESTRUCTION�Z/ (I OUT-OF-SERVICE WELL [3 GEOPHYSICAL WELL # 11 SOIL BORING <br /> . .._ q..- <br /> CI_INSTALLAT-1011-... [],IELL..,SYSTEM,.REPAIR E2 CROSS-,CONNECT REPAIR [] VAPOR EXTRACTION WELL #_�N _ <br /> UN <br /> VA�COW A I] New [3 Repair H-P. DEPTH PUMP SET FT FIRST WATER LEVEL1/µlY.L40 I <br /> (TYPE OF PUMP) MW L x Gt/ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING[7 INDUSTRIAL [7 OPEN BOTTOM DIA. OF WELL CASING <br /> (7 DOMESTIC/PRIVATE [] GRAVEL PACK/SIZE__ TYPE OF CASING TE PVC SPECIFICATION <br /> (7 PUBLIC/MUNICIPAL `[II DRIVER 1 DEPTH OF GROUT SEAL <br /> C7 IR0.I GATION/AG OTHER Id%Nkin 00'^ GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> GROUT SEAL PUMPED: 0 Yes 0 No CONCRETE PEDESTAL BY DRILLER: 17 Yes (7 No <br /> C7 MONITORING <br /> APPROX. DEPTH LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTRUCTIONIDRILLING METHOD: MUD ROTARY_ AIR ROTARY_ AUGER_ CABLE_ OTHER ` -4e5,SNVe GYO kTLH�n <br /> 1 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: "t <br /> �. certify that in the performance of the work for which this Permit is issued,-1 shaLL not employ persons subject to WORKMAN's COMPENSATION <br /> Laws of California." Contractor's hiring or sib-contracting signature certifies the following: " 1 certify that in the performance <br /> or the work for which this permit is issued, I sail employ persons subject to WORKMAN'S COMPENSATION Laws of California-" THEAPPLICANT <br /> /RUST CALL 2 HOURS ADVANCE FOR REDUIRED 1RSPECTIONS..AAT (2091466-3423. Complete drawing aat�l ower area provided. D <br /> Sig lr Title T/ .O (1e.1�_ Date&AW <br /> I <br /> - Is <br /> - <br /> ,/l- D�EEPAJ-RT'yENT USE ONLY <br /> Application Accepted By AF/ +/+I " - " Date �t+ Area <br /> j Grout Inspection By Date Purp Inspection By Date <br /> Destruction Inspection By Date - Comments: <br /> �_. ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHKXAfICASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> 3so2 00 32/83 g D 0 1 + <br /> i, <br />