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Parcel Size/APN# <br />Phone #1:19 • A-f.r.3 • 6,2'16 <br />*JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />APPLICATION FOR WELLIPUMP PERMIT <br />ENVIRONMENTAL HEALTH DIVISION <br />P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 96201-388 <br />(209) 468-3420 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete in Triplicate) <br />4ication is here by made to the San Joaquin County for a permit to construct and/or install the work described. This applicat on is <br />le in compliance with San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br />vices, Environmental Health Division. <br />Address/or APN# 1COZ 1\1 • 1()Ce014e-• City Sircklevl, <br />ier's Name A24,,,r-yrie C:-onraki Address 221 \AL Sayk..11 by.; ye) <br />:antractor CARAYWC4er GINTI,7124A.0 Address112.-S AOCIVAie 1.,3At..10 tt <br />ub Contractor &VITA \D'il1Vi115 t-Ylil(crelle41\41 AddressZ.0, 6c;< 223.1)gal4tC ituic# 026 t 1- <br />E OF WELL/PUMP: I] NEW WELL 0 REPLACEMENT WELL ?I(MONITORING,WELL4 <br />DESTRUCTION 0 OUT-OF-SERVICE WELL C] GEOPHYSICAL WELL # <br />14 INSTALLATION I] WELL SYSTEM REPAIR C] CROSS-CONNECT REPAIR <br />[] New 0 Repair H.P. DEPTH PUMP SET FT. <br />(TYPE OF PUMP) <br />INTENDED USE <br />C] INDUSTRIAL <br />I] DOMESTIC/PRIVATE <br />C] PUBLIC/MUNICIPAL <br />(1 IRRIGATION/AG <br />TYPE OF WELL <br />OPEN BOTTOM ,1 <br />14 GRAVEL PACK/SIZEM.,;) <br />I] DRIVEN 61.1"1 <br />I] OTHER <br />- MONITORING <br />,PPROX.DEPTH .5bY <br />.. <br />4. <br />IMPOSED CONSTRUCTIONIDRILLING METHOD: MUD ROTARY AIR ROTARY AUGER X CABLE OTHER <br />: <br />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 <br />following: "I <br />certify that in the performance of the work for which this permit is issued, I shall not employ persons subject <br />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 />MUST CALL 'URS A V CE FOR ALL REQUIRED INSPECTIONS 01209101-3423. <br />Complete drawing at lower area provided. <br />, rp.4— <br />, <br />C \Ar1 fa A_ Title (3V1V1IVIn106ASc)e-C1.1A4, Date 41)110 <br />4 r)n £L L-Lic./ <br />,.., , <br />SO <br />° <br />L1057 <br />/tj, <br />0 <br />5 ' %451 Phone #610-337— 1-30 <br /># qi 352 . 9553 Phone <br />I] SOIL BORING <br />FIRST WATER LEVEL <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF WELL EXCAVATION 5 ',Ac:VNeS DIA. OF CONDUCTOR CASING <br />i e <br />TYPE OF CASING/STEE s.i.-A‘Ale, it) DIA. OF WELL CASING 4 nlneS <br />DEPTH OF GROUT SEAL (4.) e..e7t- SPECIFICATION <br />GROUT BRAND NAMElleJA Fi!Alartlozratli- <br />GROUT SEAL INSTALLED BY AlreWINIe., <br />GROUT SEAL PUMPED: C] Yes (] No CONCRETE PEDESTAL BY DRILLER: 0 Yes <br />LOCKING CHESTER BOX/STOVE PIPE <br />Signed X <br />DEPARTMENT USE ONLY <br />Application Accepted By Date 3 <br />Grout Inspection By Date <br />Destruction Inspection By Date <br />61'5/ Area , <br />Date <br /> <br />Pump Inspection By <br /> Comments: 04)67 , co, <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REBUTTED CHECKMCASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br />360/ 40 .. E'r" /•?‘ -7-(1.3_.-7-71-:5z. <br />„--, ,