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APPLICATION FOR WELLIPUMP PERMIT <br /> �JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION 19fta P 0 BOX 38$ 446 N. SAN 2091JOAQUIN ST, STOCXTON, CA 96201-388120914887420 <br /> NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED MA y 2 5 <br /> 19 <br /> (Camplam is Triplicate) 'bed <br /> on is <br /> Application is here by made to the San Joaquin Canty for a permit to construct and/or install the work desELjhed,-,, NFhp�l a=Heelth <br /> made in compliance with San Joaquin County Oevel:prent Title, chapter 9-1115.3 and the Standards of San Jbb�IYII/11� 'pp'°I�IluyrTl'h/11�yrryyH <br /> EAUN <br /> Services, Environmental Health Division. $ <br /> tn/ Parcel Size/APN# <br /> Job Address/or APN# /700 81�'k ,yV "'Clry <br /> owner's NameS1 MIIS-CV LlPL� � a //P`` '�^'1 Address37¢ bhFdn C� S�Gk� `O 5�-7 Phone 2� ct <br /> 1tC (� Ly`I�'1✓74 L—Ay. �0?- Address P-o. Bv,c 2231 r� dvvl. Lic•%�72-b/Z_ Phone A �� Z- v <br /> Contractor i7,�'1 <br /> Address ll / Lic% Phone % <br /> Sub Contractor w,�� <br /> TYPE OF WELL/PUMP: )�NEW WELL U RE'h.ICEMENT WELL � MONITORING WELL Of <br /> \V— ❑ OTHER <br /> ❑ DESTRUCTION ❑ DUT-GF-SERVICE WELL ❑ GEOPHYSICAL WELL % ❑ 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 PCWP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS o <br /> E] INDUSTRIAL C7 OPEN BOTTCW DIA. OF WELL EXCAVATION O '1DIA. OF CONDUCTOR CASING IV4 <br /> a--xz - <br /> (7 DOMESTIC/PRIVATE GRAVEL PALX/SIZE 03 TYPE OF CASING/STEEL/PVC !gc 64 qD DIA. OF WELL CASING <br /> DEPTH OF GROUT SEAL J SPECIFICATION <br /> ❑ PUBLIC/MUNICIPAL C3 DRIVEN GROUT BRAND NAMESJ`'�" <br /> (IIRRIGATION/AG E2 OTHER GROUT SEAL INSTALLED BYM CF <br /> .�MONITORING GROUT SEAL PUMPED: ❑ Yes X No /y tZC_ON�CRETE PEDESTAL BY DRILLER: C3 Yes ❑ No <br /> Q LOCKING CHESTER BOX/STOVE PIPE TVat-l��G `,ax J AYa� <br /> APPROX.DEPTH go <br /> PROPOSED CONSTRUCTIONIDRILLING METHOD: MUD ROTARY_ AIR ROTARY__ AUGER, CABLE_ OTHER__ <br /> I hereby cel that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, <br /> r <br /> State Laws, and Rules and Regulations of the San Joaquin County. Hare 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 ofuarkifornha.--ich tContractorhis permit's <br /> Tissued or <br /> salt nemplcyhnc.persons signature <br /> to to WORKMAMIS fies the fCOMPENSATION Laws of California.'-ollowing-. 11 1 certify that in theTperAfPPUCAXT <br /> MUST CALL 24 HOU�IN ADVANCE FOR ALL REDO D INSPECTIONS AT 11091 468.7423. Complete drawing at tower areprovided. <br /> v"f r' Title l-`l�V1Y0h ItiR.ViV Dates l <br /> Signed X � <br /> EE <br /> DEPARTMENT USE ONLY W� <br /> L _Q --Q Area <br /> Application Accepted 'ByDate <br /> n T <br /> A / I _ <br /> Date Pump Inspection By Oate <br /> Grout Inspection By yam„ <br /> Destruction Inspection By <br /> Date Comments: <br /> 2-9ACCOUNTING ONLY: AID# FAC% O I <br /> PE CODES FEE INFO AMOUNT REMITTED CHECX11CASH RECEIVED BY DTE PERMITISER ICE REQUESST UMBER INVOICE <br /> C� v <br />