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`PLICATION FOR WELLONIP P'OM'T <br /> t*wVdAQUIK COUNTY PUlIUC HEALTH SERVICES. <br /> ENVIRONMENTAL HEALTH 01VISIOU <br /> P O 8riX 32>t. 445 ir. SANJOAndulx IT,BB.342DS OC><'IOII, CA 46ZO1.322 <br /> F IL E COPY <br /> IIaN•R�tf PERMIT EXPi S 1 �j,fIiC1A OA��O <br /> � <br /> Sam <br /> tiption is <br /> Application is here W made to the n Joaquin C>�ty for a permit to construct and/or instatt the, Loris described. This SOP <br /> wade in cam <br /> lisnce Lith San loequ{n County Devetc:Mmt Titter Chapter 9.1115.3 and the Standerds of San Jasquin County Pubtic Heatth <br /> Services. ewirorsuentat Health Division. City k"— Parcel Size/APNA� <br /> Job Address/or APNO $�Oa �Q5`T ti L �{ Phare <br /> {� /s Address �� lJ�l►� <br /> owners Nave 7ZOgtJ Phone #'707-37V-2d-1q <br /> ,m <br /> ss LiaN�ts <br /> contractor Phone <br /> Address <br /> ;ub Contractor <br /> J- OTM <br /> '1P OF VELL_/s M_P' �i.)49W YELL ❑ XeLm IIMENT WELL tI 1f011ITCRICA WELL 50 .� Q SOIL SING <br /> ❑ DESTRUCTION ❑ CUT-OF-SERVILE YELL 0 GEOPHYSICAL WELL st 1 <br /> ❑ INSTALLATION ❑ WELL SYSM REPAIR U CROSS'CONNECt REPAIR D VAPOR EXTRACTION YEt� A 1 <br /> it N.P. DEPTH PUMP SET _ FT. FIRST WATER LEVEL <br /> c3 Now D Reps ' <br /> ITTPE Of PUIP3 <br /> liumm MUSE TYPS OF n1ELLr�DiISTRUCT101t sPEpACATIONS K <br /> DIA. Of YELL EXCAVATION DIA. Of CONDUC70R CASING <br /> a INDUSTRIAL D OPEN BOTTOM <br /> 2.L'L— TYPE OF CASING/STEEL/ �{0 DIA. OF WELL CASING y <br /> ❑ OCNESTIC/PRIVATE `,CT GRAVEL PACJ;/3IZE_�,. • SPECIFICAT1CH <br /> � - _ <br /> ;3 PUSLIt/mICIPAL E3 DRIVEN DEPTH Of GROUT SEAL CAST 3XW NAME 3E.5a <br /> a IRRIGATION/AG E3 OTHER GROUT SEAL INSTALLED BY----- M <br /> GROUT SEAL PUMPED: % Yes D Na / COtICRETE PEDESTAL BY DRILLER; 13 Y65 �H No <br /> p MONITdttHG i L:p►ris�'Y� �aX <br /> APPROX.OEPTH 3S LOC>CING CHESTER 8oX/sTovE PIPE <br /> PROPOSED CONSTRUCTIONIDRILLUIG KETH.on: AWROTATT,^AIR ROTARY__ AUGER 1C__ CABLES_OTHER__. <br /> 1 hereby Ce,rtify that i haus pr:pered this sPp <br /> lieation and that the work will be done in accordant with San Jaaquin Canty ordirnnces. <br /> state Lay-, subject to•YORKHAN'S COMPENSATION <br /> and Rules and Regulatlazs of the, San �oaqu{n County. Hare owner or Licensed agent's signature certifies the. foi owwngc <br /> certify that in the performance of the work for which this Paan" is issued. I shell not anploy persons that in the perforrancO <br /> Lawn of California:" Contractor's hiring or sub-contracting <br /> s signature <br /> ig atureevtiffie?IA1hleSfCCMPEIISATIONlawarof California.,, THtAPPUCAI[T <br /> of the work for which this <br /> permit is issued, t 3FE ONS pe <br /> MUST CALL 2; URS N ADVANCE FON REDUIRED Ia45PECTIaNB AlA120!}�B•3423. Coaptete drawing at toyer` area ided. Data <br /> Signed X, te7lf, 'A <br /> Title – <br /> f I I L <br /> t - 1 1 - <br /> DEPARTMENT USE ONLY . <br /> A <br /> Date <br /> �?/ n <br /> Application Accepted BY Date <br /> Oste PuSP Inspection <br /> Grout Inspection By <br /> Oestruction inspection BY <br /> Date Coawents: <br /> ACCOUNTING ONLY: <br /> AID* FAC>r <br /> PE cants FEf <br /> AMOUNT AEMfTTED CH CCJTCASN RECEIVED BY DATE PERIUTlSEINYlC> REDDEST NUMBER INVOICE <br /> Z <br />