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XPFUCATION S WELLJeUMr rzAmaa <br /> X JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 1 ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 3811, "S X SAN JOAQUIN ST- STOCXTON, CA 86202-388 <br /> (,ZOS) 488a4ZO <br /> NON AEFUNDA9LE PER111T EXPIRES 1 YEAR FROM DATE ISSUED <br /> 6Accl cation is here by made to the San Joaquin c-my for a permit to construct and/or install the work described. This applicat cn s <br /> 1 made in compliance with San Joaquin County Oever_pment Title, Chapter 9-1115 3 and the Standards of San Joaquin County Pull c icaL-^ <br /> services, =nvirorriental Health Division a�s Jn+�11 �SJ� �1 Kelt —O C/1 YJ/ <br /> l — <br /> or Address/ar NPN# f I2O �=� a`7Z�j'TnntT 411. +'�'11 City�^ �_eze.�c-�gn _D Parael Size/APwx <br /> Owner's Name G Address—o S Phone <br /> 'antraczor i .Address-�tff 61e" Lic# 4 one io 9-Z!?n <br /> -J u / <br /> -uo Contr for mo��� (�. A�ra� � T/Lic# 7/D079 P c0V 77¢�30b <br /> 1 'YOE OF WEiL/PUMP NEW WELL 0 REPLACEMENT WELL )L MONITORING WELL # (3 OTHER <br /> 1 (3 DESTRUCTION R CTT-4F-SERVICE WELL 0 GEOPHYSICAL WELL # 0 SOIL 8CIRING <br /> (3 INSTALLATION (3 LE=TS. SYSTEM REPAIR p CROSS-CONNECT REPAIR Q VAPOR EXTRACTION ..'ELL <br /> E3 Wow (3 Repair H-P DEPTH RMP SET FT FIRST HATER LEVEL mss <br /> (TYPE OF PUMP) <br />' IWTENOED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> is <br /> r] INDUSTRIAL (3 OPEN BOTTC14 DIA. OF WELL EXCAVATION S DIA. OF CONDUCTOR CASING <br /> 1 7 DCMESTIC/PRIVATE 'jt GRAVEL PACK/SIZE TYPE OF G5I1TG/STEEL!/_PVC PVC• DIA. OF WELL CA/SING Z r <br /> ?USLIC/MUNICIPAL 0 DRIVEN DEPTH OF GROUT SEAL-6 b! dJWn+irlfd SPECIFiCATICU {D Sa-ch= C"Pm...,y <br /> ARIGATiONlAG [3 OTHER GROUT SEAL INSTALLED 8Y Cir•i 14 a r GROUT BRAND NAME---- 1:71//la,-,4 <br /> 40MITCRING r GROUT SEAL PUMPED 14 Yes 0 No T'Y CONCRETE PEDESTAL BY DRILLER A Yes 40 <br /> APPROX DEPTH i O - 80 LOCXIKG CHESTER BOX/STOVE PIPE _24 a TC AD X <br /> ?ROPOSED CONSTRUCTIDNIORILLING METHOD. MUD RCTAAY� AIR ROTARY_ AUGER, CABLE_ OTHER_ <br /> Yeredy certiry that I have prepared this appl,cation and that the work will bo done in accordance with San Joaquin County Drainances <br /> Scale Laws, and Rules and Regulations of the San Joaquin County Home owner or Licensed agent's signature certifies the -ollowing <br /> cer-,ry what in the performance of the work for which this permit Is issued, I shaLL not employ persans subject to WORKMAN'S LJMPEXSATiCw <br /> laws of California Ll Contractor's hiring or sLb-contracting signature certifies the fallowing. u I certify that in the perTormance <br /> a [ne iorr for which this permit is issued, I s.`a(l awl oy persons subject to WORKMAN'S COMPENSATION Laws of California " THE APPLICANT <br /> MUST CALL 24 HOURS Iia ADVANCE FOR ALLQUIR MPECiIONS AA"T(209) 488 34231.. Completa drawing <br /> laatt, Lower area provided. <br /> n <br /> aigned X l C ( (�S T,LLe�Ctnlo✓ P�a�eCl-_IY,dW Date9 �1; <br /> i <br /> ApQlocation Accepted By. DEPARTMENT USE ONLY Are <br /> 1 Grout Inspection By Date Pump Inspection By Oate <br /> Destruction Inspection By Date Comnents. Z <br /> 1 , � <br /> 7NO ONLY AID# FAC# Q <br /> PE CODES FEE INFO ANIOUNT "XITTED CIECI(1ICASH RECEIVED BY GATE POWISERVICE REQUEST NUMBER INVOICE <br /> 6 <br /> oZEES� 7/ 1- <br /> 1 <br />