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APPLICATION FOR WELLIPUMP PERMIT <br />AN JOAQUIN COUNTY PUBLIC HEALTH SERVI wf <br />ENVIRONMENTAL HEALTH DIVISION <br />P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201.388 <br />(209) 468.3420 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete in TTipficate► <br />APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 8-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />1, 11) ierij, lZrismA CITY 56n PARCEL SIZE/APN# InD CI sf, <br />JOB ADDRESS/OR APN# <br />OWNER'S NAME 4.,ADDRESS (Y I C7 I i AZ t Eta A�� PHONE #43 1 j <br />CONTRACTORADDRESS 1C1riCxi J1. L1C+t "5�a <br />PHONE' ` <br />SUB CONTRACTOR ADDRESS IJC# PHONE # <br />TYPE OF WELLIPUMP: ANEW WELL <br />❑ REPLACEMENT WELL <br />)54 MONITORING WELL N-mLII" 3 <br />❑OTHER <br />WNSTALLATION <br />❑ WELL SYSTEM REPAIR <br />❑ CRJSS CONNECT REPAIR <br />❑ VAPOR EXTRACTION WELL # <br />❑ New ❑ Repair <br />H.P. <br />DEPTH PUMP SET FT. <br />FIRST WATER LEVEL C <br />(TYPE OF PUMP( <br />❑ OUT -OF -SERVICE WELL <br />❑ GEOPHYSICAI. WELL x <br />® SOIL BORING 8 <br />❑ DESTRUCTION: <br />' <br />INTENDED USE <br />TYPE OF WELL <br />CONSTRUCTION SPECIFICATIONS <br />kp <br />A <br />D <br />❑ INDUSTRIAL <br />❑ OPEN BOTTOM <br />DIA. OF WELL EXC�VATION—1 [2 —sy r,e <br />PJ <br />DIA. OF CONDUCTOR CASING <br />I iV <br />D <br />❑ DOMESTIC/PRIVATE <br />IA GRAVEL PACK/SIZE <br />TYPE OF CASINGISTEEL/PVC tkF h �.0�, S, <br />DIA. OF WELL CASING -`�) <br />❑ PUBLIC/MUNICIPAL <br />❑ DRIVEN <br />DEPTH OF GROUT SEAL vQ®O <br />SPECIFICATION <br />R <br />❑ IRRIGATION/AG <br />❑ OTHER <br />GLUT SEAL INSTAIJ.ED BY R C' <br />GROUT BRAND NAME , ) <br />E <br />19, MONITORING�7 <br />GR OUT SEAL PUMPED: Yea ❑ No <br />CONCRETE PEDESTAL BY DRILLER: PI Yea 13N. <br />S <br />S <br />,t <br />APPROX. DEPTH I'�- AJ <br />�-y ,(�+1 <br />TT <br />LOCKING CHESTER BOX/STOVE RIPE <br />PROPOSED CONSTRUCTIONIDRILUNG METHOD: MUD ROTARY <br />AIR ROTARY- �_ AUGER CABLE OTHER <br />DEPART& ENT USE ONLY / ^� 2-17 <br />�/ <br />i' Date_( t� /q ( Arar2- ZZ� <br />Application Accepted By <br />Grout Inspection By Date Pump Inspection By Date <br />Destruction inspection <br />le I <br />ACCOUNTING ONLY: I AID# <br />PE CODES I FEE INFO <br />MOM <br />DATE I PERMITISBMCE REQUEST NUMBER <br />INVOICE <br />i <br />