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_.._ .. . .._ __... .# lPPL1CAT10N FOR WE}LjPOMP PERMIT <br /> ,IOAaUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIBOX 388, 44& N.SANE OA N STNTAL ,STGCXTON, CA 96201-388 .14"T # <br /> • DIVISION <br /> P O 8 ��Y� <br /> (2091 468-3420 RIECIEIVE❑ <br /> r <br /> NON.REFUNDAW PERMIT E)IP1AfS 1 YEAA fAOM DATE ISSUED �Y 1 _ <br /> iCoa�p{ata ie. �} . pp <br /> Ikf4 -Th licatian is <br /> far a permit to construct and/or install the d � Tom, _ <br /> Aaptication is here by made to the San Joaquin C Imcy Pe g' ' n Courcy P.i�liLic �lealth <br /> bevel- t Title, Chapter 9 1915.3 and the standards �a(�}Q q� :_ .. �' <br /> made in compliance with san Joaquin CouncYn �MENTAL�j�''-'" <br /> Services, Envirormental Health Division. �lVV1�0 <br /> City o e.eJ Parcel Size/APN# �Ca 9_ 58,3 <br /> Sob Addregslor APN# � � r��k�� �.✓fOr4 <br /> Address W �� Phone # <br /> Owner's Name /V f/tr.ttcl r evs p !! CrdlE�•ri .'If�4l� /7�C1 <br /> 9 L i m Phone # k: <br /> Contractorf�ri2�''/ .JV i'a✓ ^' p�Address r <br /> C 7 1-3WA/-7Phane # �[�'�SZf7YSry <br /> sub Contractor �• <br /> ,lJr,�l.'�Js Address Cu a GT9 Lim s <br /> TYPE OF WELL PUMP: [3NEW WELL II RVLACEMEN7 WELL ❑ MONITORING WELL. # (IOTHER Y <br /> SOIL BORING <br /> ' U DESTRUCTION (3 off-CF-SERVICE WELL ❑ GEOPHYSICAL HELL #_ �YAPOR EXTRACTION YELL #� <br /> q [I WELL ELL SYSTEM REPAIR U CROSs-CoNNECT REPAIR. P;• FIRST WATER LEVEL <br /> rj New ❑ Repair H.P. DEPTH PUMP SET <br /> _FT. <br /> OF PIMP) <br /> 1NTE3iDED USE TYPE OF Well CONSTRUCTION SPECIFICATIONS c� <br /> C7 INDUSTRIAL I] OPEN BOTTOM <br /> flIA. OF WELL EXCAVATION. d � DIA. OF CONDUCTOR CASING <br /> C] DOMESTIC/PRIVATE C7 GRAVEL PACX/SIZE TYPE OF-CASING/STEEL/PVC CIG DIA. OF WELL CASING <br /> ❑ PUBLIC/MUNICIPAL C] DRIVEN <br /> DEPTH OF GROUT SEAL_ L-0 � SPECIFICATION . _ <br /> C7 IRRIGATION/AG C] OTHER GROUT SEAL INSTALLED $Y 0r,` c ✓ GROUT BRAND NAME' <br /> GROUT SEAL PUMPED: Yes ❑ No CONCRETE PEDESTAL BY DRILLER: 0 Yes <br /> C] MONITORING Na <br /> APPROX.DEPTH_ Sa — LGCXING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTRUCTIONiORILLING METHOD: MUD ROTARY_ AIR ROTARY_. AUGER ✓ CABLE, OTHER <br /> hereby certify that I have prepared this ape/:cation and that the work wit/ be done in accordance with San Joaquin County Ordinances, <br /> State Laws, and Rules and ReguLations of the San Joaquin County. Hcme•owner or Licensed agent's signature certifies the. fai[owing: "t <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. szb-contracting signature certifies, the fo(lowing: .1I certify that in the performance <br /> o-" the ,ark for which this permit is issued, I s.Lall emptoy persons subject to WORKMAN'S COMPENSATION Laws of California_" THE APPLICANT <br /> 1IUST CALL 24 H URS IN ADVANCE FOR ALL EOUIRED MISE i;IR S A7{2113}488.3423. Complete drawing at lower .area provided. i <br /> Title : Gt.I4 e-i-0etes'�" <br /> signed X <br /> k <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Area <br /> ja� <br /> Grout Inspection By Date -? PtuQ Inspection By Date <br /> destruction Inspection By Date Comments: <br /> ACCOUNTING ONLY: AID* FACS <br /> PE�CODES, JFEE INFO AMOUILf REMITTED ptEi:7(iICASH REIY D 8Y r BATE" PEAMIT1SE31YICE AEffUEST NUMBER INVDICf I� <br />