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APPLICATION FOR WELLIPUMP PERMIT �v J <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P,O. BOX 3M,3(4 EAST WEBER AVENUE, STOCKTON, CA SSM -388 <br />(109) 469.3410 <br />MON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete In Triplicate) <br />APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN 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 <br />19-11 116_.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR //APNI _Q(� R�y-� �/ ILAM rA clrr LC L PARCEL SIZE/APNI <br />OWNER'S NAME-TY�. 1(117. mut rJl Try�7SWi .��TM] ADDRES8�C.Ir4 S�r S-6(�(„� PHONEI <br />CONTRACTOR Sir(JL11 fyl,�' A�(Z �(�ADDRESS Z.3(. S K)tsL. A" SIr J IJC1&2.5�YPNONE I <br />SUB CONTRACTOR T' <br />ADDRESS UC/ <br />PHONE # <br />TYPE OF WELL/PUMP; ❑ NEIN WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL # ❑ OTHER <br />❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS -CONNECT REPAIR ❑ VAPOR EXTRACTION WELL # <br />11New13Repolr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br />(TYPE OF PUMP) O <br />❑DESTRUCTION: <br />❑ OUT -Or SERVICE WELL ❑ GEOPHYSICAL WELL # <br />601E <br />U BORING <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED CIIEC f�+� AHII <br />INTENDED USE <br />TYPE OF WELL <br />CONSTRUCTION SPECIFICATIONS <br />❑ INDUSTRIAL <br />❑ OPEN BOTTOM <br />A <br />DOMESTIC"IVATE <br />❑ GRAVEL PACK/SIZE <br />DIA. OF WELL EXCAVATION <br />DIA. OF CONDUCTOR CASINO n <br />PUBLIC /MUNICIPAL <br />❑ DRIVEN <br />TYPE OF CASINO/STEEL/PVC <br />DIA. OF WELL CASINO n <br />IRRIGATION/AG <br />❑ OTHER <br />DEPTH OF GROUT SEAL <br />SPECIFICATION R <br />MONITORING <br />GROUT SEAL INSTALLED BY <br />GROUT BRAND NAME E <br />GROUT SEAL PUMPED: ❑ Yea ❑ No <br />CONCRETE PEDESTAL BV DRILLER: ❑ Vee []No S <br />APPROX. DEPTH <br />� �QQ� <br />LOCKING CHESTER BOX/STOVE PIPE <br />PROPOSED CONSTRUCTION/DRFLUNO METHOD: MUD ROTARY <br />AIR ROTARY AUGER <br />_ 5 <br />CABU OTHEq disc s�. <br />DEPARTMENT UBE ONLY <br />Appkstlon Accepted By k"'"- <br />/ _ <br />Grow I-PMt1 � BY /I/ P f.`✓' /J , ` Date4� <br />P—p Insper:tion By____ <br />Oeatnretlon Irnprwalon By <br />Cemmdrta� /`""� lSt4 or(YV <br />Dote l U 0 Arse <br />Dale <br />ACCOUNTING ONLY: <br />AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED CIIEC f�+� AHII <br />RECEIVED By DATE <br />PERMIT/SERVICE REQUEST BER INVOICE <br />Pub. Health Serv. - Enviro. 173 (3/96) <br />