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`_��APPLICATION FOR WELLAMP PERMIT - — -- —_ <br /> SAY JOAQUIN COUNTY PUBLIC HEALTH SERVICES u' <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 SOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 96201.388 <br /> (209) 468.3420 <br /> pQN•RETUpDABLE PERk11T EXPIRES 1 YEAR F10M DATE ISSUED <br /> I <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 Develcpmant Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br /> Services, Environmental Health Division. <br /> Z- 1-16, 11'i City S���LZO A/ Parcel Size/APN# <br /> Job Address/or APN# -/- -L <br /> C � GK e z* - Address Pik J�l�G t C i-° s e ?Y Phone #_ <br /> Owner's Name <br /> ✓c �r 1z., Address Phone #7-7 31y�7i��`� <br /> Contractor /� <br /> ���� 4�H ✓i✓�;;L%Address14 i I ZE tip# Phone # <br /> Sub Contractor <br /> TYPE OF YELL/PUMP: NEW WELL ❑ REPLACEMENT WELL 11 MONITORING WELL #_ [7 OTHER 2 <br /> [] DESTRUCTION [I OUT-OF-SERVICE WELL [] GEOPHYSICAL WELL # <br /> Q SOIL BORING <br /> INSTALLATION L, WELL SYSTEM REPAIR [] CROSS-CONNECT REPAIR [] VAPOR EXTRACTION WELL # <br /> 0 New [] Repair H.P_ DEPTH PUMP SET FT. FIRST WATER LEVEL Sc, <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> r <br /> DIA. OF WELL EXCAVATION � DIA. OF CONDUCTOR CASING <br /> [] INDUSTRIAL [7 OPEN BOTTOM 4 <br /> (] DOMESTIC/PRIVATE GRAVEL PACK/SIZEy TYPE CASING/STEELA C 5 � G _ DIA. OF WELL CASING Zr� <br /> EPTH ©f�GRQUT SEAL SPECIFICATION -�� Si �E� <br /> C] PUBLIC/MUNICIPAL U DRIVEN L. - T�cR`�Lgy� <br /> IRRIGATION/AG [] OTHER GR T SEAL/INSTALLED BY GROUT BRAND NAME <br /> 1 MONITORING GROUT\SEPL PUMPED: � Yes Cl No / CONCRETE PEDESTAL BY DRILLER: Yes [] No <br /> I <br /> APPROX.DEPTH �S LOCKING CH TER B0�/STOVE PIPE <br /> f A r <br /> PROPOSED CONSTRUCTIONIDRILLING METHOD: MUD ROTARY_ AIRROTARY— AUW <br /> CABLE OTHER <br /> ItI`C.�` <br /> [ hereby certify that I have prepared this application and` t hp-work 'till be 'done in accordance with San Joaquin County Ordinances, <br /> Slate Laws, and Rules and Regulations of the San Joaquin Count .,:•Rome owner--or licensed agent's signature certifies the fol towing: "i <br /> certify that in the performance of the work forralich this permit itr issued, I shall not employ persons subject to WORKMAN'S COMPENSATION <br /> Laws of California." Contractor's hiring or stb-contracting signs eI.c r, ifies Lite following: " I certify that in the performance <br /> �%of the work for which this permit is issued, I s`all employ persons su ct to WORKMANrS�COMPENSATION Laws of California." THE APPLICANT <br /> MUST CALL I4 HOURS,IN ADVANCE FOR ALL REQUIRED IRSPECTIONS AT(2091488-3423. i,(pt'e'tedrawing t lower area provided. L <br /> Signed X y <br /> Litt 7 _c ✓ u�c.� Date f <br /> V \ <br /> DEPARTMENT USE ONLY \ <br /> Date Area <br /> Application Accepted By <br /> Date_ Pump Inspection By Date <br /> Grout Inspection By <br /> Y? Comments: <br /> Destruction Inspection By --� � � A ��i ate <br /> _- _ -------� <br /> ACCOUNTING ONLY: AID#- <br /> FAC <br /> PE CODES FEE INFO AMOUNT REMITTED CHECXitCASH RECEIVED BY DATE ERMITISERVICE REQUEST NU INVOICE <br /> 9 <br /> 3 ov 2- <br />