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DATE <br />*manna ONLY: AID* <br />AMOUNT REMITTED FEE INFO PE CODES <br />00 <0 • lb 0 <br />-PPLI-CATION FOR WELIWUPAP PERMIT <br />. JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P 0 BOX 31111. 445 N. SAN JoAaUIN ST., STOCKTON, CA 95201-388 <br />(209) 488.3420 <br />11011•REFUNDARLE PERMIT EXPIREs I YEAURom DATE ISSUED <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 Titte r Chapter <br />Services, Environmental Health Division. <br /> 9-1115.3 and the Standards <br />and/or install the <br />City <br />/33a AL <br />6-7 <br />Sub Contractor <br /> Address /3qc Y/52)2_ SIZ:(--kk 4?52.c‘c. <br />Address ?lc) t tic* <br />Job Address/or AM* /,151::, <br />owner's wage Address <br />Contractor i)i( (A) Zrs--Pt/Li4-7 <br />Phone * 47 /6 6 —7 DO/ <br />Phone 0 707 -3 7 Y-2-cF4.5-- <br />P hone # -zaq -77Z -342-a <br />wok described. This application is <br />of San Joaquin County Public Health <br />Parcel Size/APN0 <br />riL2E.A111.5L-4P: /NEW WELL <br />DESTRUCTION <br />INSTALLATION <br />New U Repair <br />REPLACEMENT WELL <br />OUT-OF-SERVICE WELL <br />WELL SYSTEM REPAIR <br />H.P. <br />'--41 MONITORING WELL a -25 <br />6 GEOPHYSICAL WELL 0 <br />0 CROSS-CONNECT REPAIR <br />DEPTH PUMP SET <br />0 OTHER <br />)2(SOIL BORING 11 <br />0 VAPOR EXTRACTION WELL 0 <br />FT. FIRST WATER LEVEL 1714r' <br /> <br />(TYPE OF PUMP) <br />IRRIGATION/AG <br />4 MONITORING <br />APPIDX.OEPTN <br />PROPOSED CONSTRUCTIONICIAIUINO INETH00: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br />73g.;Wiertify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, <br />certify that in the performance of the work foruhich this permit is issued, I shall not <br />employ persons subject to.WORKMAN'S COMPENSATION \./) <br />State Laws, and Rules and Regulations of the San Joaquin County. Home owner or licensed agent's signature certifies the following: "I (, ) <br />Laws of California." Contractor's hiring or sth-contracting signature certifies the following: n I certify that in the performance -----__ --) <br />of the work for which this permit is issued, I shall errptoy persons subject to WORKMAN'S COMPENSATION laws of <br />California." THE APPLICANT <br />- 2 AtAL4A-4------ <br />Complete drawing at Lower area provided. <br />Title ./l-g- ,..' DateL/1/_1947: <br />/ <br />MUST CALL 2 HOU IN AD <br />L <br />ANCE R ALL REQUIRED UISPECTIONS AT 1201) 404423. <br />i <br />iIrmm.1............".......... <br />.. <br />••••,.1.11•1. <br />41•••-- <br />USE TYPE OF WEU <br />INDUSTRIAL 0 OPEN BOTTOM <br />DOMESTIC/PRIVATE )1 GRAVEL PACK/SIZE -415 <br />PUBLIC/MUNICIPAL a DRIVEN <br />OTHER <br />.30 <br />poisTRycimpSPECIFICATION$ a <br />DIA. OF WELL EXCAVATION 5/ DIA. OF CONDUCTOR CASING <br />TYPE OF CASING/S1EEL/65 DIA. OF WELL CASING ,2'l <br />DEPTH OF GROUT SEAL Jiediam- OkiariO4-/ SPECIFICATION 17)d2A/ LA9 <br />GROUT SEAL INSTALLED BY 4-re1414v"L--/- GROUT BRAND NAME /3L 64i( le_ <br />GROUT SEAL PUMPED:111Yes 0 No CONCRETE PEDESTAL BY DRILLER: CI Yes <br />LOCKING CHESTER BOX/STOVE PIPE <br />Signed X <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />DEPARTMENT USE ONLY <br />Date 551 2=i(TI Pump Inspection By <br />Dat0 COMMentS: <br />Area <br />Date <br />CHECK/MASH <br />FAC0 <br />RECEIVED BY