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APPLICATION FOR WELIJPUNIP PERMIT <br /> JAN JOAOUIN COUNTY PUBLIC HEALTH SERVI( <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 446 N. SAN JOADUIN ST., STOCKTON, CA 96201.388 <br /> (209) 488.3420 <br /> NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (ComPlate is Trplkate) <br /> Application is here by made to the San Joaquin County for a permit to construct and/or install the work described. This application is <br /> made in compliance with San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br /> Services, Environmental Health Division. <br /> Job Address/or APN# !A 91 r'i Li1I &A 1�12/OT .f cii�ty' �5��� 1 Parcel Size/APN# <br /> Owner's Name `CIW-f0a.1 t_1WIAg r-l" Address IOi$3 gLg_+-!, <br /> [)A�ye- Phone #477-O84(i <br /> O84(—Contractorc� C= 'Aadress 18d3af Laa„L <br /> ) u% L°O�v- f Lic# �' Phone #/�J�'Ue y� <br /> Subcontractor - A ress�„ tfL <br /> / _, Lic#(p?— <br /> W U M,Lt J ®` 4 <br /> TYPE OF WELL/PUMP: "EW WELL [I REPLACEMENT WELL ❑ MONITORING WELL # 13 OTHER <br /> [I DESTRUCTION [) OUT-OF-SERVICE WELL [) GEOPHYSICAL WELL # [) SOIL BORING <br /> [3 INSTALLATION [I WELL SYSTEM REPAIR Q CROSS-CONNECT REPAIR PK VAPOR EXTRACTION WELL # �GoZ <br /> New ❑ Repair N.P. DEPTH PUMP SET FT. FIRST WATER LEVEL r- o <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> G N <br /> [) INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WELL EXCAVATION i7 DIA. OF CONDUCTOR CASING <br /> ❑ DOMESTIC/PRIVATE W GRAVEL PACK/SIZE 49-1.7 TYPE OF CASING/STEEL/& DIA. OF WELL CASING a2K <br /> ❑ PUBLIC/MUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL VAe-ti-�5 SPECIFICATION ,l <br /> [I � <br /> IRRIGATION/AG ❑ OTHER GROUT SEAL INSTALLED BY f�'lI .. GROUT BRAND NAME `Inaa4-lw.f <br /> E7"RONITORING GROUT SEAL PUMPED: [I Yes FYNo CONCRETE PEDESTAL BY DRILLER: ;rYes ❑ No <br /> APPROX.DEPTH 6 L> rn l LOCKING CHESTERIk/STOVE PIPE <br /> PROPOSED CONSTRUCTIONIDRILLING METHOD: MUD ROTARY_ AIR ROTARY_ AUGER `CABLE_ OTHER_ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Sen 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, 1 shall not employ persons subject to WORKMAN'S COMPENSATION <br /> Laws of California." Contractor's hiring or subcontracting signature certifies the following: " 1 certify that in the performance <br /> of the work for which this permit is issued, 1 shall employ persons subject to WORKMAN'S COMPENSATION Laws of California." THEAPPUCANT <br /> MUST CALL 24 HOURS IN ADVANCE FOR ALL REatHRREDD (INSPECTIONS AT(205)468.3423. Complete drawing at/-fl_owe/r area provided. <br />__- - 11 *111��Y2 —_Sit1 _IYC�I C�./L.4 Date//2y _ <br />