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2-17 <br /> —1998 1 0: 1 0AM FFA <br /> P 1 <br /> APPLICATION FOR WELLJPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SEAVICES <br /> ENViRONMENTTAL HEALTH DIVISION <br /> P O 1Wx 388, 445 N.SAH 10AaU1N STS STOCKTON. CA 95205-38S <br /> 2031468-3420 <br /> NON N DARLILE901411 EXEIRES J-V'E_A4FRO RI DATE Issil Eii <br /> A=0 cation is here by made to the San Joaquin Canty for a permit to eaurruct and/or Instalt the work described_ This apptfcation is <br /> mace in compliance with San Joaquln County OeyeLOpaent Title, Chapter 9-1115.3 and the Staraiarda of San jaayuin County Public kcal;n <br /> ' ;crvlces, Envirmoentpt Health Division, <br /> .ro sa6ress/or AP90. -� City <br /> Jtinrr s 4,me_�g, fV KPS Parcel Silt/APNY <br /> Address <br /> 1 -1-1$'nk Phene 4KOf` <br /> Go�tractvr_ i �1A�i4rev► } G 11 6oL�e a�A c i&�l�S Phone g `T if• <br /> P Address L DnYa a ♦ a 1-7C) <br /> euro .ont-ac[or� £YV��f�a��t�1Q <br /> Address �• 075 {. RtO�L <br /> —� u�xlaoRog Phone * 3`74-,2SIG- <br /> 7-PE <br /> S7-PE CF WEL PUnP• ❑ NEW WELL U AVULCEMENT YELL ❑ KONITOIING WELL Y i7 O7NER <br /> ❑ DESTRUCTICNi ❑ WT-Of-SERVICE WE" ❑ GIfiOPNT5ICAL WELL I Sol L,BORING//04NC� (r'I} <br /> N I) INSTALLATION ❑ WELL STSTTJt REPAIR 11 CROSSCONNECT RVAIR ❑ VAPOR EXTRACTION WELL R <br /> Q Nee Q Repair H.P. DEPTH A" SET FT. FIRST WATER LEVEL <br /> "'PE OF PVKP) <br /> INTTNDFD USE T--PT E of WFtI CON57RUCTION SPECIFICATIONS <br /> ,; INDUSTRIAL ❑ OPEN BOTTOM DIA. OF DELL EXCAVATION `t DIA, OF CONDUCTOR CASING N A <br /> 0CMES1IC/PRIVATE p GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVL--LJJ� DIA, OF WELL CASING _N�A <br /> 'V5L;C/MUNICIPAL L3 DRIVEN DEPTH OF GROUT SEAL x+ ;10—a SPECIFICATION_ key--4 C' <br /> IARIGATION/AG T) OTHER, GROUT SEAL INSTALLED BY U , GROUT BRAND NAME <br /> [i 4OMITOO ING GROUT SEAL PUMPED: (] Yes �No CONCRETE PEDESTAL ST DRILLER. Arcs I] Ho <br /> �PROX. DEPTH C7 LOC7CINc CNiESTER BW/STOVE PIP <br /> :r-+ <br /> ADPDSED CONSTRUCTIOWDRLU1NG METHOD: MIA AOTAIT_AIR ROTARY_ AUGER CAiLti, OTHER ✓ (G edProbP—) <br /> hereby certify that I have prepared this appt,.eation and that the work mitt be done in an:aordanea With San Joaquin County ordinances, <br /> state Law3, and Mules and Regulations of the Qn Joaquin Canty. Hage aver or Licensed agent's slrwture certifies the foltowing: 11 <br /> =er ify that in the Perforollaxe of the Work for Wich this permit is issued, L shall not aaptvy persons subject te•WO ROAN'S CGMPENSATIOw <br /> _aws of California," Contractor's hiring or ub-contracting signature Certifies the fotlowina: e I certify that in the perFormence <br /> the cork for uhieh this permit t issued, I s...all eVtoy persons subject to WORKMAN'S COMPENSATION Laws of Catifornia." THEAPKICAIT <br /> JtuST CALL 24 NOURPU ADY CE FON L REOOIREA awwTIONS AT ROY)aB LIZ]. Comleta drawing at lower area provided. �p <br /> >>qn 7( <br /> T1 I. <br /> i 9ireZ"1�'/U <br /> i I <br /> LJ - 1- 1 1 1 1 1 . 1 FI R11111i Tli 7-1 <br /> I - <br /> I I <br /> I <br /> II <br /> UVANTMEINT USE ONLY 2 p <br /> Apotleation Adapted ry l 4� �(/ Date 02 ' r 5a Area <br /> Grout Inspection By gate Inspection By Date <br /> Oes Trucrion Inspection By pace-- <br /> A <br /> ate-- CooN+ents: <br /> ACCOUNTING ONLY: AID# FACT <br /> I <br /> PE CODES FEE IV4 AM@Wff AEILITTBD CR•CINICAsx xftaVEO By GATE PER11fT1Bi:RYIC! AERIii sT IFUNBFA INVOICE <br />