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4PPUCATIEN FCR WELL1PUMP PIRMIT <br /> SAKI JOA11I1IN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O SOX 3SE, 445 #L SAN JCAl1UlIfi ST., STDCXTON, CA 85201-388 <br /> (2091 458-340 <br /> 10111.15:UA04BL1:7ERVEr EXPIRES i YEAR MM DATT?ISSUED <br /> ICaaivLau � <br /> lfrl on is here by made to the San Joaquin Cxnry far a permit to constrtiet and/or inszaiL the work desc-ibed. This ap+oLication is <br /> oe in ccrptiance with San Joaquin County Ocyclzpoent Title, Chapter 4-1115.3 and the Standards of San Joacuin County PiaLic Health <br /> rvices, EnvirarmentaL Health oivtstion. Q I <br /> a ACCreSS/or APIi�F ��� 6,!!22,9 Z-n-7 /�pqn Cid, �C7re7-6 N Parcel Size/ApNS <br /> ner's flame Address ' ! !4D Phone <br /> ��E 7 <br />^ivac:or./^r'e ��cn� ErJyiRCnlr►iFr�Iry /.t/CAddrsssSC'�i e:}Y�e..! TszTN/1t f7�Y1+R� Lied A11A Phone <br /> Z antrac.or iGrlE G QQ/�/Nrs uJCA0 ' Add es / P �C Li e3 Phone <br />�S OF WE! vvuP- ;Z� HEW UEU ❑ XULACEIEIIT WELL MutTORING WELL s � ❑ OTHER <br /> ❑ DESTRUCTION ❑ =-OF-SERVICZ WELL ❑ GF"I(7siCkL 1ELL 0SOIL BORING � <br /> ❑ INSTALLATION I3 W--f SYSM REPAIR © CRIISS-COHNE_''T REPAIR CT( E%TRAC ION VET ':e,1�2\ <br /> ❑ Nese ❑ Repair H.P. DEPTH PUMP SFT FT. FIRST WATER irve-, � I <br />'Pc Or PLFIP) <br />:f0E0 USE TYPK OF WET-1 CUMMUCTiON SPE£TFTCATTONS <br /> � <br /> r ll !1 <br /> NDUSTRIAL 0 OPEN BOTTOM DIA. OF WELL EXCAVATION t3 DIA. OF CONDUCTOR CASIxG <br /> I.CMESTIC/PRIVATE 731� GZAVEL PA=/SIL 3 TYPE OF CA5IHWSTESL/PVC ✓C DIA. OF WELL CAS IXG 2 �r `i' Z{'�� s <br /> PUBLIC/KJNICIPAL ❑ DRIVEN DEPTH OF Gacur SEAL JOd�°E�iF.Fi/ir�trff SPECIFICATIONY/ ZAL<AC (�rrt.✓jT r s�i7?� <br /> IRZIGATICH/AG ❑ OTHER GRCUT SEAL INSTALLED BY C.e/LCCr7?l GRCUT BRAND NAME z � <br /> 4CWITORING r GROUT SEAL PUMPED- X Tes ❑ No CONCRETE PEDESTAL 3Y DRILLER- Q Tes No <br />'R= DEPTH ` 80 LOCXIHG CHESM BWSTOVE PIPE /00 N <br /> P CDASTSUCTIONIDRILLING LEETFI= AUD RarAZY AIR ROTARY_ AUGaa—x— CABLE_^,., OTHER_ <br /> 7 <br /> erect' cerclTy tnaC I have Prepared this apcL.ution and zhat the work will be dare in a=reanca with San Joaquin County Ordinances, <br /> re Laws, and Rules and Regutations of the San Joaquin County. Home owner or Licrnaed agent's signature certifies the -ollawing. <br /> that in the perrormance OT the work for>esic:i this Permit is issued, I shall not eoplay persons subject to WORZ}lAN'S =XPEIISATION <br /> s or CaLiTornia.° Contractor's hiring or ux-contrac-zing sigriatwe certifies the foLLowing. ° I certify that in the perrormance <br />--ie sort for which this permit is issued, I stall emoiny persons subject to UORTOIAIleS COHPERSATION Laws of Ca[ifornia." TRE APPUClXT <br />"+ CALL 24 HO S IN ADVANCE FOR ALL A$LIUIHED PECTIGH AT=11 4a8.34Z3. Coapiete drawing at Lower [area proviCed. <br />-I ed, Title.�i�/}'r1^r�/r_T/�j<� bare� 'Pf o <br /> DEPARTMENT USE ONLYq z a <br /> kation Accepted Hy2Date V /0 Area V O <br /> it Inspection By. Date <br /> Pump Inspection 8t' care— <br /> ruction Inspection By Date Caennents f/6 qJ6 •�� <br />=UNTING ONLY- I AID# FAC* <br /> E CODES I FE: INFO AMOUNT REMITTED � CIIEi=USH REI;FIYED BY DATE � PE3LMMSERVICE REaUEST HUMBER I INVOICE I <br /> J I I <br />