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Pump Inspection By Date <br />Comments: Date <br />Date <br />ACCOUNTING ONLY: AID* FAC# <br />1V70 <br />RECEIVED BY <br />/41 <br />INVOICE FEE INFO PE CODES <br />87 <br />AMOUNT REMITTED CRECXXCASH DATE <br />APPLICATION FOR WELL/PUMP PERMIT <br />IAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P 0 80X 388, 445 N. SAN JOAQUIN ST., STOCXTON, CA 95201.388 <br />(2091 458-3420 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FRO <br />ICampiate 4111110011 <br />Application is here by made to the San Joaquin Caunty for a permit to construct <br />made in compliance with San Joaquin County Develccment Title, Chapter 9-1115.3 <br />Services, Environmental Health Division. <br />Joo Aacress/or APN# 4)Avoezxt2 City Parcel Size/APN# <br />PAYMENT <br />RECEIVED <br />.0.N 30 1c16 ,4, <br />M DATE ISSUED SAN JO 1,j11\4 COUNTY <br />PUBLIC HEALTH SERVICES <br />and/or install thNOWN4gAikdi..14rATI-WrIlklgVA is <br />and the Standards of San Joaquin County Public Health <br />Address .512.5- "Itri 51,e66 Phone 0 <br />51,/7-i7 9 j <br />/A/C Ackiress.51.9 gkeisli Li a .c//'1 Phone Contractor // re,v <br />Sue Contractoriliiic/i4 0/2/14/4/6 Address/'. /.1114K ,-7102.5 4P4k410 egIVAA4ML i 67W /I Phone <br />7YPE OF WELL/PUMP: 391 NEW WELL <br />DESTRUCTION <br />INSTALLATION <br />New 0 Repair <br />REPLACEMENT WELL )5 MONITORING WELL $ <br />OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL $ <br />SYSTEM REPAIR 0 CROSS-CONNECT REPAIR <br />H.?. DEPTH PUMP SET FT. <br />0 OTHER <br />1 SOIL BORING <br />la'VAPOR EXTRACTION WELL <br /> <br />FIRST WATER LEVEL .— -.77'"J <br /> <br />(TYPE OF PUMP) <br /> <br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br />'i 0 <br />iNDUSTRIAL 0 OPEN BOTTOM DIA. OF WELL EXCAVATION 0 ,r /0 DIA. OF CONDUCTOR CASING <br />0 DOMESTIC/PRIVATE --]Nr GRAVEL PACK/SIZE)7_...) TYPE OF CASING/STEEL/PVC /4ii,/,(: DIA. OF WELL CASING . ' ..". '' \i- /7i'l 41' -- <br />PUBLIC/MUNICIPAL 0 DRIVEN DEPTH OF GROUT gEA L16 Ls( zWtrave49 SPECIFICATION 6 <br />0 IRRIGATION/AG 0 OTHER GROUT SEAL INSTALLED BY ae/I.a.:(e... GROUT BRAND NAME yvA <br />MONITORING GROUT SEAL PUMPED: A Yes 0 No CONCRETE PEDESTAL BY DRILLER: 0 Yes X No <br />APPROX. DEPTH ./C - :7,'JC' LOCKING CHESTER BOX/STOVE PIPE NO <br />PROPOSED CONSTRUCTIONIDRILLING METHOD: MUD ROTARY AIR ROTARY AUGER /)( CABLE OTHER <br />lereoy certify that I have prepared this apcl:cation and that the work will be done in accordance with San Joaquin County Ordinances, <br />Stare Laws, and Rules and Regulations of the San Joaquin County. Home owner or licensed agent's signature certifies the following: <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 ',4ork for which this permit is issued, I s!..all employ persons subject to WORKMAN'S COMPENSATION Laws of California." THE APPLICANT <br />MUST CALL 24 HO 'SIN ADVANCE FOR ALI REWIRED LISPECTIONS AT (2050 483.3423. Complete drawing at lower area provided. <br />Title, M-fr, ez-77r Date --26-17 <br />(/ <br />••• <br />Owner's Name <br />Signed X <br />DEPARTMENT USE ONLY <br />Application Accepted By Date <br />Grout Inspection By <br />Destruction Inspection By <br />A/7‘ A ,abe'l