Laserfiche WebLink
APPLICATION FOR WEL14PUMP PERMIT <br />..u411 JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCXTON. CA 96201-388 <br />ROI 468-3420 <br />NON-RERADABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Camp late <br />Application is here by made to the San Joaquin C..lunty for a permit to construct and/or install the work described. This application is <br />made in compliance with San Joaquin County Develcpment Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br />Services, Environmental Health Division. <br />Job Address/or APN# ;2.3 4J,," M- n City STarert, Parcel Size/APN# <br />Address itifa 511 J/a)2f <br />Spirr9 <br />Contractor /101:/ t.rt CIO 0 )/ e c,,01( ,:rAz ,nic Address 42;11/ Kika, rencifrie. Lic# A/A <br />Sub Cont ract or A/ OP/41-w1/6 ("vie,: Address /O. A:vc / e4A.eno Cre.€1011. c# 6'7•7,‘ty <br />Phone * <br />Phone #(476/93C -,-‘1170 <br />Phone (Q/ )?'S -9551( <br />Owner's Name 64.2.:-17:4),41/Qte <br />TYPE OF WELL/PUMP: II NEW WELL <br />DESTRUCTION <br />INSTALLATION <br />New 0 Repair <br />REPLACEMENT WELL 0 MONITORING WELL # <br />OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL # <br />SYSTEM REPAIR 0 CROSS-CONNECT REPAIR <br />H.P. DEPTH PUMP SET <br />OTHER <br />SOIL BORING <br />VAPOR EXTRACTION WELL *4;2 O \ <br />FT. FIRST WATER LEVEL ----470 / <br />(TYPE OF PUMP) <br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br />0 INDUSTRIAL El OPEN BOTTCM DIA'. OF WELL EXCAVATION 3' 7r IC DIA. OF CONDUCTOR CASING <br />TYPE OF CASING/STEEL/PVC DIA. OF WELL CASING " Ai') <br />0 OCMESTIC/PRIVATE 0 GRAVEL PACK/SIZE <br />0 DRIVEN DEPTH OF GROUT SEAL -i0 aal7ederP,Afei' SPECIFICATION ..7,/c4A ,(..s.:A(6-0--rE4414 <br />0 PUBLIC/MUNICIPAL <br />0 IRRIGATION/AG 0 OTHER GRCUT SEAL INSTALLED BY ceizckle. GRCUT BRAND NAME <br />GROUT SEAL PUMPED: 0 Yes (3 No CONCRETE PEDESTAL BY DRILLER: 0 Yes No <br />MONITORING <br />APPROX. DEPTH ae LOCKING CHESTER BOX/STOVE PIPE <br />MUST CALL 24 HO SIN ADVANCE FOR ALL REQUIRED PECTIONS AT (209)488.3423. Complete drawing at lower area provided. <br />TittJ0e4c7, P7:77e./^ <br />V <br />PROPOSED CONSTRUCTIONIORILLING METHOO: MUD ROTARY AIR ROTARY AUGER A CABLE OTHER <br />I hereby certify that I have prepared this applcation 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 tne '.4cor for which this permit is issued, I all egploy persons subject to ADRKNAN'S COMPENSATION Laws of California." THE APPLICANT <br />• <br />Date <br />c> <br />Signed <br />Date Area a6gY <br /> Date <br />406 g&77e ei0N5 <br />Application Accepted By <br />Grout Inspection By <br />DEPARTMENT USE ONLY <br />Date Pump Inspection By <br />Destruction Inspection By Date Coments: <br />ACCOUNTING ONLY: AID# 1 FAC# <br />RECEIVED BY DATE INVOICE <br />PE CODES FEE INFO AMOUNT REMITTED 1 CSECX/ICASH PEFCMITISERVIC : a do pa ,•. • <br />.50/ VillA) 67 44 5g6 Zc't A-0.3. q1100 ?.34/6 ) <br />_ ---'" <br />1