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APPLICATION FOR WELLIPUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIt...4 <br />ENVIRONMENTAL HEALTH DIVISION <br />P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201-388 <br />(209) 488-3420 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete ie TripBeate) <br />Application is here by made to the San Joaquin County for a permit to construct <br />made in compliance with San Joaquin County Development Title, Chapter 9-1115.3 <br />Services, Environmental Health Division. <br />Job Address/or APN#\OOZ_104..)04e- City CrirCKiCAPV <br />Owner's Name {'eC (----CliriDA\I <br />Contractor ClAiArC^414- CI 111 , --.1-4, 1.0 . Addressit AliallkiC ANii"-.,2 <br />Sub contractor l'1141)44.5m6A=11 Addressto,E '4Bi flill vA _ .11,7 CatA04LLic# ti.) 1:2(11- <br />/ <br />) <br />TYPE OF WELL/PUMP: 0 NEW WELL 0 REPLACEMENT WELL K MON1TORiN ,i1Lle-IA9‘ 11 '. k( OTHER <br />0 0 0 0 <br />q1V1_, <br />DESTRUCTION OUT-OF-SERVICE WELL GEOPHYSICAL WELL # SOIL BORING <br />lig INSTALLATION 0 WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR IIIL VAPOR EXTRACTION WELL #4, <br />0 New 0 Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br />(TYPE OF PUMP) <br />0 L1'6L o/v6 <br />gl <br />and/or install the work described. This application is <br />and the Standards of San Joaquin County Public Health <br />Parcel Size/APN# <br />Address 223 (.14,..17),try Phone # 2oci, I's <br />itekici Phone C", 331.3130 <br />Phone <br />OTHER <br />INTENDED USE <br />INDUSTRIAL <br />0 DOMESTIC/PRIVATE <br />0 PUBLIC/MUNICIPAL <br />0 IRRIGATION/AG <br />1,‘ MONITORING <br />APPROX. DEPTH <br />PROPOSED CONSTRUCTIONIDRILLING METHOD: MUD <br />CONSTRUCTION SPECIFICATIONS <br />!..,AtLkes <br />IN2A-.11e, it) <br />4? -ce.Aelt* <br />Vreim' <br />GROUT SEAL PUMPED: 0 Yes 0 No <br />LOCKING CHESTER BOX/STOVE PIPE <br />ROTARY AIR ROTARY AUGER X CABLE <br />DIA. OF CONDUCTOR CASING <br />DIA. OF WELL CASING IA Inc.11e-:› <br />SPECIFICATION <br />GROUT BRAND NANEVICIAV Forit'avi,C611-"kt <br />CONCRETE PEDESTAL BY DRILLER: 0 Yes <br />TYPE OF WELL <br />OPEN BOTTOM <br />)11. GRAVEL PACK/SIZEit: <br />0 DRIVEN 6t.16X <br />0 OTHER <br />DIA. OF WELL EXCAVATION <br />TYPE OF CASING/STEE <br />DEPTH OF GROUT SEAL <br />GROUT SEAL INSTALLED BY <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, <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 which 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: " I certify that in the performance <br />of the work for which this permit is issued, I shall employ persons subject to WORKMAN'S COMPENSATION Laws of California." <br />THE APPLICANT <br />URS A V CE FOR ALL REQUIRED INSPECTIONS ATI2010488.3423. Complete drawing at lower area provided. <br />>r\y1/4k, , C WI';;•/ 1k4rY.0 <br />DEPARTMENT USE ONLY <br />Application Accepted By Date <br /> 5 Areak <br />Grout Inspection By <br /> <br />Date Pump Inspection By Date <br /> <br />MUST CALL <br />Signed X <br />Title 61vimilmte c-.7)peA4414) Date <br />C., CA,t1.1.4,(4er Coe 44 ;Eric , <br />Destruction Inspection By Date Comments: >1)- 1/ QJ / <br /> <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK/ICASH RECEIVED BY DATE PERNHTISERVICE REQUEST NUMBER INVOICE <br />360/ 40 g?- . <br />dd., 'a <br />/ 6 <br />115b r"" <br />r 7—,tift97111‘,