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APPLICATION FOR WELLIPUMP PERMIT <br /> ,6lX JOAQUIN COUNTY PUBLIC HEALTH SERVICE` <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 38k 446 N. SAN JOAQUHY ST.,-STOCKTON, CA 96201388 <br /> (209) 488.3420 <br /> MON.REFUNDABLE PERMIT EXPIRES t lAR FROM DATE ISSUED <br /> malate is swam <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 Oevelopsxnt Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br /> Services, Environiaental Health Division. <br /> Job Address/or ! 7 7 / 8 7A � IMM City -�4c-y y(,P�aarr"ceel Size/APM* <br /> OwneN s Mame Gvrn Address 5 Q-�� �V /rte- 'L T Phone�i�i <br /> Contractor D}}� CVMM I N S =A%�4ddrsft '0.0X/ 284LI� icd Phone ��/�Sub Contractor it. P � ress 11383-A rel; W L i c0 SSZO("- „hone 0 / 853-x!94 <br /> � •� 9sb Sao <br /> TYPE OF HELL/KPV: NEW WELL E] REPLACEMENT WELL 0 MONITORING WELL 0 U OTHER <br /> 0 DESTRUCTION 0 OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL 0 0 SOIL BORING <br /> 0 INSTALLATION 0 WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELL 0 <br /> [] New I] MP Repair N.P. DEPTH PUSET FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) - __ -- _ <br /> INTU EO USE TYPE OF VML CIMSTIRICTIOM 511MICATIONS <br /> 0 INOUSTRIAL 0 OPEN BOTTOMDIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING <br /> 0OM <br /> DOMESTIC/PRIVATE GRAVEL PACK/SIZE 3 yawl TYPE OF CASING/STEEL/PVC / e DIA. OF WELL CASING <br /> 0 PUBLIC/MUNICIPAL 0 DRIVEN DEPTH OF GROUT SEAL -S��IU� SPECIFICATION <br /> a IRRIGATION/AG [] OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> XMITORING I GROUT SEAL PUMPED: [] Yes 0 No CONCRETE PEDESTAL BY DRILLER: 0 Yes 0 No <br /> APPROX.DEP'TN MPLIC LOCKING CHESTER BOX/STOVE PIPE FLUSH All: 13 � <br /> raw So CONSTRUCTHONORILLING METNOO: MUD ROTARY_ AIR ROTARY_ AUGER CABLE_ OTHER_ <br /> 1 hereby certify that I have prepared this apptication and filet the work wit1.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 which this permit is issued, I shall not employ persons subject to WOIIQMAN'S COMPENSATION <br /> Laws of California." Contractor's hiring or sub-contracting signature <br /> subject t iignaturcertifies the <br /> SfoOlowing: " I certify that in TION Laws of California."the <br /> THEAPPmancee <br /> of the work for which this permit is issued, I shalt employ per <br /> UCANT <br /> MUST CALL 24 NOUN OVANCE FOR ALL REQUIRED NISPECTIONS AT(2001498-3423. Complete drawing at Lower area provided. <br /> Signed X Title (Je'°��` Date���� <br /> DEPARTMENT USE ONLY <br /> Application Accepted By <br /> ✓ /� Date C 7 Area <br /> Grout Inspection By Date Pump Inspection By Date <br /> Destruction Inspection By Date Comments: <br /> ACC1011=BNLY: AID* FACS•: <br /> PE CODES FEE INFO AMOUNT REMTTED CNECKSICASM BECEIVED BY DATE PERMITIZERVICE REQUEST NifWER INVOICE <br /> 3�01 773 � <br />