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APPLICATION FOR YIIE •P..,V PERMITS' QU1H COUIIY PI �LG��ii' ALTH SERVICES <br /> } VIRONME'NiTAL Hl iiTH DIVISION <br /> P 0 SOX 38A, 445 H. SAN JOAaUIN ST, STOCKTON, CA 96201,388 <br /> (209) 458.3420 - <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED -. <br /> (ramplorw is I@Wm) <br /> ,oplication is here by made to the San Joaquin C.xncy for a permit to construct and/or instaLL thework described_ This application is <br /> ade in compliance with San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaouin County Public Health <br /> :arvices, Environmental Heatth Division. ! h <br /> .ob Address/or APN# f _CIS—T �,y�0,✓�� � City `at rdi✓ Parcel Size/APN# _ <br /> ;When's Name Address%a..r W. /h ' C �747Phane #d4��$3 <br /> - - - - <br /> -ontrsctor_ orrrrzrO.,�>��Jt/_r!1^�ndld Addressnr/ r�L�F��r 'Ii Phone <br /> ub contractor V 1�w �/'.r Address/=esr(�.��7Ty / T y�i�� Lie* 7�Z f-0 ^I Phone # <br /> 3' <br /> :YPE OF WELL/PUMP: U NEW WELL [] REPLACEMENT WELL [] MONITORING WELL # (] OTHER <br /> x DESTRUCTION (] OUT-CF-SERVICE WELL [] GEOPHYSICAL WELL # (] SOIL BORING <br /> (] INSTALLA-T1AN-,],SELL-SY:STEM-,REPAIR-�-❑�CROSS=CANNECT:REPAIR [ VAPOR EXTStACT[ON4W[LL <br /> _ <br /> 'TYPE OF PUMP) [] New 0 Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> l <br /> 8TENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �'r��;TIP IIII,-V '%C,r, -e //C"V �J J <br /> _ INDUSTRIAL (] OPEN BOTTOM 01A. OF WELL EXCAVATION 9 DIA. OF CONDUCTOP CASING (' / <br /> :i DOMESTIC/PRIVATE C] GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA: OF WELL CAS;HG' <br /> :) PUBLIC/MUNICIPAL Q DRIVEN DEPTH OF GROUT SEAL SPECIFICATION .. <br /> i IRRIGATION/AG [I OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME_ <br /> I ,4C9ITORING GROUT SEAL PUMPED: C] Yes I] No CONCRETE PEDESTAL BY DRILLER: (] Yes (I No + <br /> zPPROX. OEPTN LOCKING CHESTER SOX/STOVE/PIPE 5S• ?-.r V/ <br /> 'RUPOSED CONSTRUCTIONJORILLING METHOD: MUD ROTARY AIR ROTARY ` AUGER I/ CABLE OTHER <br /> /70 <br /> 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 Sw Joaquin County. Home owner or licensed agent's signature certifies the f&Lowing:'"I <br /> =ertify that in the performance of the work for which this permit is issued, I shall not employ persons subject to WORKMAN'S COMPENSATION <br /> aws of California," Contractor's hiring or sub-contracting signature certifies the following: 11 1 certify that in the performance <br /> ,; the work for which this permit is issued, I stall employ persons subject to WORKMAW S COMPENSATION Laws of California." THE APPLICANT <br /> 1AUST CALL 24 HOURS IN ADVANCE F ALL REDUIRED 115PECTIONS AT(202)488.3423. Complete drawing at Lower area provided: <br /> i fined <br /> ✓✓ Title�P� �P �O /�/ Oate ��� <br /> TTT;I <br /> I <br /> DEPARTMENT USE ONLY r <br /> alica[ion Accepted By� Date Area <br /> :rout Inspection By Date Pump Inspection By "� Dare n <br /> "estruetion Inspection BY. Date Comments: <br /> ACCDUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED DHEi17(#ICASH RECEIVED BY DATE PERMITISERVICE REOUEST NUM8E JG ie D <br /> 2-7-s� <br /> ZA <br />