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,IPPLICATiaN FOR WEWPUMP PERMIT <br />' IN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P D SOX 388, 445 C SAN JOAaUIN ST., STOCKTON, CA 95201.388 <br /> maxi 45$-1420 <br /> NOJt gEIqIiIQAeLE PEglIiT EXPIRES i YEAR FROM GATE ISSUED <br /> 600Licatian is here by made to the San Joaquin C-,.nry for a permit to construct and/or instaLL the work desclili, it� rl .l c <br /> race in convitiance with San Joaquin County oeve+apnent Titte, Chapter 4-1115 3 and the Standards of San !ce<< ,1 L0011} I v I <br /> iervices, Envirormental Health Division <br /> .3�F,ico nr-* �,4/ /y S7� <br /> .co AcwresS/ar APNS Z-/ 0 E— 141 mm r 2tZ7C9try �1] Parcei siw i <br /> F <br />' tuner's Name C.C!� MQ r �n G' Address l` t ��d� A_ <br /> _.,ncractor h'DrJ 6ddress- ��� l7/ricl�-J+l� l✓ AL1 � <br /> � #-- lll�—� �,' l6) <br /> 1� /f'C7 <br /> �oAConc "ictar cd! �/ I AddP��. _ 7S1'a , C.4 j5z/ L�# 'J/d0 <br /> -At + 4 - <br /> 2+ �� z `7 <br /> "voc ofyEl,l/PVM� � NEW WELL p �l.ACEjiENT WELL )LMONITORING WELL # � OTi.Lr; f �./�C L 5 <br /> p DESTRUCTION Q OUT-OF-SERVICE WELL p GEOPHYSICAL WELL # SOI1 6(,, ,tiC _ <br /> R INSTALLATION ❑ W—L SYSTEM REPAIR 0 CROSS-CONNECT REPAIR VAPOI 10 t <br /> a Now a Repair H.P DEPTH PUMP SET FT FIRST Wl 1 ,'II <br /> i-YPr F PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS � <br /> N <br /> rNDUSTRIAL Cl OPEN BOTTCH OIA OF WELL EXCAVATION_ /O DIA. OF CONDUCIat x1119( <br />' aCHESTIWPRIVATE A GRAVEL PACz/SIZI; -3 TYPE OF CASING/STEEL/PVC DIA. OF WELL CA'lh G 0r <br /> I PUBLIC/MUNICIPAL El DRIVEN DEPTH OF GROUT SEALZ�g6e a�i7�+r>-»+fn6d SPECIFICATION (0 ��k jfti�7 Cha -T <br /> s <br /> j IRRIGATION/AG CI OTHER GRCUT SEAL INSTALLED BY r111di'' GROUT BRAND NAiI <br /> MONITORING r7 / I GROUT SEAL PUMPED. 1( Yes 0 Me CONCRETE PED ESIAL Il DkILLtR <br /> APPROX DEPTH /D " �O b59 LOCXING CHESTER BOX/STOVE PIPE /70 7re7"t!G <br /> PROPOSED CONSTRUCTIONiORILLIXG METHOD MUD ROTALZY_ AIR ROTARY_ AUGER CABLE_ OTHER_ <br /> iere0y CerttTy that I have prepared this appL.cation and that the work will ba done in accordance with San Ic vi ccxnty 4roin. <br /> state Laws, and Rules and Regulations of the San Joaquin County Home owner or Licensed agent's signature certifies she -ollowinq <br /> z:zrtlTy -hat to the perrortnarice of the work for wnich this permit is issued, I shall not employ persons subject to 111=lxI CLxtPEk"AT :w <br /> -aws of California ° Contractor's hiring or ssti-contracting signature certifies the following: " I certify ti t in tie perfo <br /> 3 ze jorx for which this permit is issued, I s.,aLL employ persons subject to WORXKAN+S COMPENSATION Laws of Cal} Iii 1HEAPI, C <br /> ULIST CALL 24 HOURS IN DVANCE FOA ALL RUIR 111PECTIIOONS AT(2091 488 3423.! Complete drawing at Lower area pro,,i<< - <br /> Signed X ` • L- •G• 1 35 TitlesBl110r'R01 �'Y�4j?a 76ro...174 f <br /> - - _ - <br /> Q E i ; <br /> 77 <br /> DEPARTMENT USE ONLY <br /> Applstatton Accepted By Date <br />' Grout Inspection By Date Pump Inspection By _ A <br /> lc <br /> )esruction inspection By Date Commaents. <br /> 1 ACCOUNTING ONLY AID# FACS <br /> LZ t <br /> �� PE CODES FEE 1NF0 AMOUNT REMMED CHE=CASH RECEIVED HY DATE PEIWTISERYICE REDUEST NU1t8Elt INVOICE .�- <br />