Laserfiche WebLink
- — — APPLICATION FOR WELUPUMP PERMIT <br /> S-9!a''JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCXTON, CA 95201.388 <br /> (209) 458.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> i — hl <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 Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br /> Services, Environmental. HeesDi <br /> HealthDivision. <br /> C <br /> Division. <br /> � � <br /> Job Address/or APN# � C� ` tit ��' City v W` Parcel Size/APN# <br /> Owner's Name <br /> >�4 ����l U L 'ddress Ste— Phone <br /> •,�,�J <br /> Contractor ., 4"t CSLI +�'t11" "''"^Address Z� ' L�/ -t Phone <br /> Sub Contractor R J �V iI� Address 13o)( 5� �')D lI1 S L i c#(v � /�w Phone #7Q 7`37(f"zed <br /> TYPE OF WELL/PUMP: NEW WELL [] REPLACEMENT WELL MONITORING WELL # V� 1 [] OTHER <br /> DESTRUCTION (] OUT-OF-SERVICE WELL [] GEOPHYSICAL WELL # [I SOIL BORING <br /> [] INSTALLATION [] WELL SYSTEM REPAIR [] CROSS-CONNECT REPAIR [] VAPOR EXTRACTION WELL # <br /> [] New [] Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> [] INDUSTRIAL [] OPEN BOTTOM DIA. OF WELL EXCAVATION ! b DIA. OF CONDUCTOR CASING <br /> Q DOMESTIC/PRIVATE [] GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVCSrl/_� �{O DIA. OF WELL CASING .�-j` <br /> [] PUBLIC/MUNICIPAL [] DRIVEN DEPTH OF GROUT SEAL '15 f"r SPECIFICATION 'ate SC'f` <br /> [] IRRIGATION/AG (] OTHER GROUT SEAL INSTALLED BY fl/t✓NN1it GROUT BRAND NAME P6r�iGµ <br /> MONITORING f GROUT SEAL PUMPED: kr Yes 0 No CONCRETE PEDESTAL BY DRILLER: Yes 0No <br /> APPROX.DEPTH 70 LOCKING CHESTER BOX/STOVE PIPE Y t,� <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 ;an 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 `n <br /> or the cork for which this permit is issued, I s}all employ persons subject to WORKMAN'S COMPENSATION Laws of California." THEAPPLICANT <br /> MUST CALL 24 H URS ADVANCE FOR ALL REQUIRED IISPECTIONS AT (209)488.3413. Cwplete drawing at Lowe p�ided. l�S <br /> Signed X �; Title Date 6 1 <br /> V' <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Are. 6f <br /> Grout Inspection By Date Pump inspection By Date <br /> Destruction Inspection By Date Comments: <br /> ACCOUNTING ONLY: AID# FAC# :J <br /> PE CODES FEE INFO AMOUNT REMITTED CHECXACASH RECEIVED BY DAT PERMITISERVICE REGUEST NUMBER INVOICE <br /> 350► °% <br /> '(0 1 q 7 D 7/& 5 <br />