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APPLICATION FOR WELLIPUMP PERMIT <br /> SA aQUIN COUNTY:�°URLIC iiEALTH SERVICES t <br /> l ENVIRONMENTAL HFALTH DIVISION <br /> P 0 80X 388, 445 N. SAN JOAQUIN ST.. STOCKTON. CA 96201-388 4 <br /> {2091 468-3420 <br /> NON•REFIINDARLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complets in IWNMI L - w <br /> Application is here by made to the San Joaquin Canty for a permit to construct and/or instaLL the work described. This application is <br /> made in compliance with San Joaquin county Deyetcpment Title, Chapter 4-1115.3 and the Standards of San Joaquin County Public Health <br /> services, Environmental Health Division. <br /> Job Address/or APN#_,C 1 �.S U S/ J�.v10.t1[ -_-\ city <br /> �v [d c��[�CYi�r✓ /Parcel�jSize/APN# <br /> Cwner's Name U1 I a-Alof- _ itJt_ Address�av`~ _ /-hi,-d L! l__. /TG,eJIo/ d / OPhone * <br /> / .S d o ldP.r/t'ao '// ?Ir7r' ' <br /> Contractor#6U err+20` J9f�N / Addressn } H,WS Phone <br /> '0o <br /> Sub Contractor AddressLic# a"I <br /> Phone # <br /> TYPE OF WELL/PUMP: Q NEW WELL {3 RE?LAC>MENT WELL [3 MONITORING WELL # Q OTHER <br /> DESTRUCTION 0 OUT-OF-SERVICE WELL [3 GEOPHYSICAL WELL # ❑ SOIL BORING + u <br /> [3 INSTALLATION` p` <br /> [7''WE.''L:SYSiE}I''REPAIR��[]rOR055-CONVECT" REPAIR= ❑-VAPOR EXTRACTION'WELL # <br /> 0 New 0 Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> i <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS (',{JS,'% /1fo1v.'f*"-'1'S y- Ifu;avrW /I S <br /> (I INDUSTRIAL [3 OPEN 30TTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING <br /> c DOMESTIC/PRIVATE [3 GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA. OF WELL CASING <br /> [3 PUBLIC/MUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> (I IRRIGATION/AG (I OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> - I <br /> Q 40NITORING GROUT SEAL PUMPED: Q Yes 0 No CONCRETE PEDESTAL BY�DRILLER: ❑ Yes [3 No <br /> APPROX. DEPTH LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTRUCTIONIORILLING METHOD: MUD RCTARY_ AIR ROTARY AUGER (/' CABLE OTHER - Q,%� c <br /> i hereby certify that 1 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: "I <br /> certify that in the performance of the work for which this permit is issued, I shall not employ persons subject to WORKMAN'S COMPENSATION <br /> Laws of California." Contractor's hiring or sub-contracting signature certifies the following: " 1 certify that in the performance <br /> o. the .cork for which this permit is issued, I s?:all employ persons subject to WORKMAN'S COMPENSATION Laws of California." THE APPLICANT � <br /> TRUST CALL 24 HOURS IN ADVANCE FOR All REQUIRED IKSPECTIONS AT(209)488.3423. Complete drawing at lower area provided. <br /> I <br /> Signed X �✓ Title ,; oat-/ <br /> - 9 <br /> f <br /> DEPARTMENT USE ONLY r g <br /> Application Accepted By Date / ` Area <br /> Grout Inspection By Date Pump Inspection By Date <br /> Destruction Inspection By__ Date Lomments: Z U�/� <br /> MMD <br /> ACCOUNTING ONLY: AID# FAC# <br /> -Z- -7 ' <br /> PE CODES FEE INFO AMOUNT REMITTED CHEMACASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> IIf4{ <br />