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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN dOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION D <br /> P 0 BOX 388,445 N. SAN JOA0111N ST, STOCKTON, CA 96201388 <br /> (2091438-3420 <br /> MAY 2 3 1995 <br /> NON RZTUNDABtE PEAMIT EXPIRES I TEAR FROM DATE ISSUED <br /> (Complete 5'K IM <br /> Application is here by made to the San Joaquin County for a permit to construct and/or install the w&Nc. ti+1W14fl tion is <br /> made In compliance with San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of Sa�i� � Health <br /> Services, Environmental Health Division. 1l <br /> Job Address/or APN# $'776' City �G?r _ Parcel Sixe/APB# �3—�`�O~ �� <br /> Owner's Name I Address ��BOX Dior rTA• CAi 9 5'376 Phone # VD ::I 4f57 <br /> Contractor Address PO$0 X ;L%47 f U Lt c# AIA Phone <br /> i <br /> Sub Contractor L.S Etc ZaeA.-TIOiJ S U Address %& I [/ Lict,16. Phone p[707-74s- <br /> TYPE OF HELL/PUMP NEW WELL U REPLACEMENT WELL MONITORING WELL # 3 U OTHER <br /> U DESTRUCTION U OUT OF-SERVICE WELL U GEOPHYSICAL WELL # [] SOIL BORING <br /> )C INSTALLATION U WELL SYSTEM REPAIR U CROSS-CONNECT REPAIR U VAPOR EXTRACTION WELL # <br /> (] New (] Repair H P. DEPTH K14P SET FT. FIRST WATER LEVEL 15 <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> [] INDUSTRIAL (] OPEN BOTTOM DIA. OF WELL EXCAVATION OIA. OF CONDUCTOR CASING i <br /> [] DOMESTIC/PRIVATE p>; GRAVEL PACK/SIZE�- 6 TYPE OF CASING/STEEL/PVC TV( __ DIA. OF WELL CASING <br /> (] PUSLIC/MUNICIPAL [] DRIVEN DEPTH OF GROUT SEAL 'i 3 n SPECIFICATION <br /> [] IRRIGATION/AG [] OTHER GROUT SEAL INSTALLED BY SES GROUT BRAND NAMEI&W-grAlkCY�'iEA�'If YY�I Z <br /> MONITORING GROUT SEAL PUMPED: 4 Yes El No CONCRETE PEDESTAL BY DRILLER: Q Yes (] No <br /> TY LOCKING CHESTER BOX/STOVE PIPE Td E !Pg <br /> APPROX DEPTH ao <br /> �OPOSED cONSTRUCTIONiURILUNG 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 Sen Joaquin County Ordinances, C <br /> State Laws, and Rules and Regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following "I <br /> certify that in the performance of the work for winch 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 <br /> of the work for which this Kermit is issued, I shall mploy persons subject to WORKMAN'S COMPENSATION Laws of California " THE APPLICANT <br /> MUST CALL 24 HOURS IN ADVANCE FOR ALL REOUIRED DISPECTIONS AT (202)45a 3423. Complete drawing at lower area provided cc5 <br /> Signed X Title Oat 64 <br /> LL Lf <br /> DEPARTMENT USE ONLY /Q(� <br /> Application Accepted By este_�'li Area yy <br /> Grout Inspection By Date Pump Inspection By Date <br /> Destruction Inspection By Date Comments 3&441k <br /> U _ <br /> a <br /> ACCOUNTING ONLY AID# FAC# <br /> PPE CODES FEE INFO AMOUNT REMITTED <br /> ;;:G1;SI1 REC iVED BY DATE PERMITiSERVIC> REQUEST NUMBER INVOICE <br /> 1 Z G [ <br />