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APPLICATION FOR WELUPbMP PERMIT �- <br /> �!<i JOAOUIKCO.UNT`f PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388. 446 b. SAN JOAOUIN ST, STOCXTON, CA 96201-388 <br /> (209) 468-MG <br /> HON-RE=iTNDABLE PERMR EXPIRES T YEAR FROM DATE ISSUED <br /> (Ca"late is Tripinatai <br /> Application is hereby made to the San Joaquin :minty for a permit to construct ane!/or install the work described. This application is <br /> Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County �1ic tllh <br /> mace in compliance with San Joaquin County 5" <br /> Services, Environmental Health Division. <br /> '��o.cy Parcel size/APN# 6-Sac�G S <br /> Job Address/or APN# 13 1-+(:D1-J. Gr`} Li.+< (L�gy�o.' City (TIC)- <br /> 0 <br /> t �� L: _ Address p 0 Qox SOS S�..Q�--�-; CA 9`I5'83 -0g 159, Phone t 1 -6`�3 <br /> Owner's Name C Ikey''Q"` ' <br /> Contractor Wa-��"� pt-t�.Vo~`"^� Address(2 <br /> 02 K.,.1,,.�ky (4, 4& -L 6 2(o Phone # S�3-30}3 <br /> Address Lic# Phone <br /> Sub Contractor # <br /> TYPE- OF YELL/PUMP' XNEY WELL IACEMEHT WELL XNONITORING WELL # ❑ OTHER <br /> ❑ i2- <br /> E3DESTRUCTION [3 CUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL #�_ ❑ SOIL BOILING <br /> VAPOR <br /> ❑ INSTALLATION ❑ yL-L SYSTEM REPAIR ❑ CROSS-CONNECT REPAIRFT. FIRST OAT RACI .LON WELL # <br /> q New [3 Repair N.P. DEPTH PUMP SET <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> DIA. OF CONDUCTOR CASING <br /> q INDUSTRIAL [3 OPEN BOTTOM DIA. OF WELL EXCAVATION _ 2„ <br /> TYPE OF CASI11G/STEEL/PVC PVC DIA. OF WELL CASING <br /> q DOMESTIC/PRIVATE q GRAVEL PACK/SIZE 5 SPECIFICATION <br /> DEPTH OF GROUT SEAL <br /> q PUBLIC/MUNICIPAL Cl DRIVEN C¢r�„+ ..,� �3r...,•�.�,..;� <br /> ❑ IRRIGATIONIAG ❑ OTHER <br /> GROUT SEAL INSTALLED BY ATfD GROUT BRAND NAME <br /> MONITORING , GROUT SEAL PUMPED: ❑ Yes ❑ No CONCRETE PEDESTAL BY DRILLER: (3 Yes [3 No <br /> S <br /> LOCKING CHESTER BOX/STOVE PIPE <br /> APPROX.DEPTH t <br /> PROPOSED CDOSTRUCTIOWDRIWIIG !METHOD: MUD ROTARY_ AIR ROTARY AUGE;_,2� CABLE,__ OTHER_ <br /> I hereby certify that I have prepared this apoliotian 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' eject toture �fies WORKMANCSfoCOMPENSATION <br /> certify that in the performance of the work for which this permit is issued, I shall not employ pe <br /> rsons Laws of California." Contractor's hiring or subcontracting signature certifies the following: " 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 /> MUST CALL 24 OU 1 ADVANCE FOR ALL REQUIRED 1»ECTIONS AT (2091 439.3423. Complete drawing at Lower area provided. `� <br /> �..ILl Title P��l��� t�l�--.�� DateT/EhL <br /> Signed X <br /> ( <br /> I <br /> DEPARTMENT USE OCLY <br /> Date —�� Area <br /> Application Accepted By <br /> Date Pump Inspection <br /> BY Oate <br /> Grout Inspection By <br /> C Date Comments: <br /> Destruction Inspection By _ - <br /> ACCOUNTING ONLY: AID# FACS <br /> PE CODES FEE INFO AMOUNT REMITTED CBEC"CASH RECEIVED BY I DATE P(71N61RISEAYICE AEffU��ER INVOICE <br /> o 3 z3 7 <br /> J J <br />