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APPIICATICN FOR Y/ELLIPUMP PERMIT <br /> _..A JOADUIN MINT,( PUSLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 388. 4a N. SAN Jn AOa88 3 , ,STOCKTONCA 96201 <br /> I .3BB <br /> Noo.lEFUNDARIE PERMIT EXPIRES 1 YEAR FROM <br /> DATE ISS <br /> -- UED <br /> i�N�1Msl lication is <br /> in C,,r y in County "tic Health <br /> t for a permit to 9-liiugt aryl/or instal( the work described. This app <br /> APpllcation is here by node to thein Count ewlopment Title, Chapter 9-7115-3 and the standards of San Joeou <br /> cede in c F, vience with sen Jeaqu L <br /> services. Envi rommntal Health Division. T7�,� ParceL Si <br /> re/APNM J,�-�-- <br /> WI(Sot1 W CttY -77-717 <br /> Job Address/or APN# pl' S C� $ �OG{;'17� Phone AI <br /> 3'! tl w'L' <br /> �0++� ✓0 <br /> Owner's WW 7 —� Address <br /> Licey Phone <br /> Addrs 172'36 Lo <br /> L rl�l ess SS2.1fSS9 <br /> contractor a v //�Lic# Phone 0 41�^ <br /> Address <br /> ${� Contractor <br /> 4j;J <br /> nem ❑ NEN WELL (7 REPLACEMENT WELL C7 GEOPHYSMONITORICAL <br /> WELL #❑ DESTRUCTION ❑ OJT•Of-SERVICE HELL (7 GEOPNYSIGL WELLY RACTI <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR EPTNOPUMPOSETCT REPAIR FT, am <br /> ❑ Mer <br /> 11 Rapalr N.P. <br /> (TYPEOF PUMI <br /> MT USE TYPE QF WEIL CCONSTRUC710P SPECIFICATIONS <br /> DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR GSIMG <br /> [3 INDUSTRIAL ❑ OPEN BOTTOMDIA. <br /> OF CASING/STEEL/PVC �� DIA. OF WELL CASING <br /> ZE_ �— <br /> ❑ U INONESTIC/PRIVATE GRAVEL PACK/SIDEPTH OF GROUT SEAL 157 SPECIFICATION <br /> ❑ PUH.JC/MUNICIPAL EJ DRIVEN GROUT SEAL INSTALLED BY GROUT BRAND NAME N <br /> ❑ IRRIGATION/AO ❑ OTHER <br /> GROUT SEAL DIB/PEO: (7 Yes 1�'Na CONCRETE PEDESTAL BY GRILLER: 0 Yes o <br /> ❑ IgNITORING Isf _ <br /> APPROX. DEPTH LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTBUCTIONIDAILLING METHOD: MUD ROTAAT__ AIR ROTARY__ AUDI CABLE__ OTHER_ <br /> 1 hereby oarti that i have prepared thio applleation and that the work will bo done (n accordance with San Joaquin County Ordinances, <br /> ignature ce <br /> state Law, aasd Rules and Regulations of the San Joaquin County. Nave owner shall <br /> licensed spent' ctors subject to�WWORKMANo'S}COMPENSATION <br /> certify that in the perforeRlnee of the work for Which this permit Is issued, I shall not employ Pe „ 1 certify that In the performance <br /> Laws of California.• Contractor's hiring or sub signature certifies the follarlts9: <br /> of the cork far in.- <br /> this permit is issued, I stall deploy persons subject to WORKMAN'S COMPENSATION laws of California-" THE APPLICANT <br /> RUST CALL 24 NQUAl/IN ADVANCE FOR ALL FOR INSPECTIONS AT 12011 4Ba'7427. conplote drewinQ at lawer'er/ea provided. <br /> (1 IIsn>'`L b rtue �rsf`� Date/o /3�8 <br /> DEPARTMENT USE ONLY <br /> Date l/'�-Q �yCl( Are. <br /> Appiicatian Accepted By <br /> Grout Inspection By <br /> De It aS Gv Pump Inspection BY Date <br /> Destruction Inspection 0y <br /> Date Comments: <br /> ACCOUNTING ONLY: AID# PAC# <br /> Pe COGEN FEE INFO AMOUNT REMITTED CASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br /> -7 6Ll eL <br />