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APPLICATION FOR WELLAMP PERMIT -- <br /> N.,.�JOAQUIN COUNTYPUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION z <br /> STOCKTON, CA 9620 <br /> ¢.l�� (209) 468.3420 <br /> NON-REFUNDABLE PEANIIT EXPIRES 1 YEAR FROM DATE ISSUED <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 DeveLof:ment Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br /> Services, Environmental Health Division. <br /> Job Address/or APN# ?l0 f CV,tk- City Parcel Size/APN# <br /> Owner's Name •' {1 LJ-F- 1 d�r2 S Address 8COC R 2,3 J(�Yx-_2 0 '1110 ( Phone # q`f y—3c �S? <br /> Contractor U R_ -iocj Address �D� J`^[ lit V � Lic# -77Q Phone # 7bZlX74 �S <br /> Sub Contractor Address Lic# Phone # <br /> TYPE OF WELL/PUMP: NEW WELL [] REPLACEMENT WELL MONITORING WELL #. J W_47 [7 OTHER <br /> [7 DESTRUCTION C] OUT-OF-SERVICE WELL [] GEOPHYSICAL WELL # A SOIL BORING Z- <br /> INSTALLATION El WELL SYSTEM REPAIR [] CROSS-CONNECT REPAIR D VAPOR EXTRACTION WELL # <br /> Q New [] Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL $� <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> [I INDUSTRIAL C] OPEN BOTTOM DIA. OF WELL EXCAVATION I? DIA. OF CONDUCTOR CASING <br /> [] DOMESTIC/PRIVATE A GRAVEL PACK/SIZE 010 TYPE OF CASING/STEEL/62, DIA. OF WELL CASING 2�( <br /> [I PUBLIC/MUNICIPAL [] DRIVEN DEPTH OF GROUT SEAL 81 SPECIFICATION 5 Lt <br /> [] IRRIGATION/AG [] OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME Pt,-?- L-(1P <br /> MONITORING GROUT SEAL PUMPED: 'El Yes f( No CONCRETE PEDESTAL BY DRILLER: C] Yes), No <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE CX- <br /> PROPOSED CONSTRUCTIONIORILLING METHOD: MUD ROTARY_ AIR ROTARY_ AUGER CABLE_ OTHER_ <br /> I 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 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' I certify that in the performance <br /> of the work for which this permit is issued, I shall employ persons subject to WORKMAN'S COMPENSATION Laws of California." THE APPLICANT <br /> 11UST CALL 24 1UR IN AD ANC OR ALL REQUIRED INSPECTIONS AT(209)488-3423. Complete drawing at Lower area provided. <br /> Signed X tvV) Title ✓e5� Oate/C �&�� <br /> H1111. 11 n1old 1 <br /> DEPARTMENT USE DULY /q may` <br /> Application Accepted By Date L ✓/-� ` *7 Areae <br /> Grout Inspection By Date Pump Ins'pe`ction By Date <br /> Destruction Inspection By Date Comments: Y ' � <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECXiNCASH RECEIVED BY DATE PERNUTISERVICE REQUEST NUt IBER INVOICE <br /> 3 <br />