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PERMIT <br />HEALTHSAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL <br />1 • • , ,' , <br />NON-REFUNDABLE. DATE ISSUED <br />ADDRESSJOB 1��i1 ,It .! <br />OWNER NAM r 6nli.' .•ADDRES <br />crrympl / PHONE .► :.� <br />CONTRA• •.� �� /iii • .. • r a �_ /1• <br />CITYIZIP .r iii ',el�it4. <br />GEOGRAPHICAL1N: COORDINA <br />f-SECTION <br />INSTALLATION:. WELL SYSTEM REPAIR . CROSS-CON14ECT REPAIR III•.• <br />1 &ZMCGE <br />t <br />INTENDED <br />TYPE OF 1 1 1 <br />■ INDUSTRIAL . OPEN BOTTOM WELL EXCAVATI. . 1 . • • <br />DIA- <br />■ .• ■ GRAVEL <br />DIA <br />0 PUBLICIMUNICIPAL D DRIVEN GROUTSEALDEPTH <br />• <br />■ , J HR NCDTK0fiiR GROUT BRAND NAMEL_ <br />■MONITORING GROUT• ■ YES ■ <br />3 NO <br />■ BOX ■ STOVE1 ,•i ■ YES ■ <br />NO <br />1APPROXIMATE/ , <br />PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY- AIR ROTARY - AUGER - CABLE - OTHER <br />i <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />.JOAQUINC1UNTY ORDIANCES, STATE LAWS, AND RULES AND/ OF SAN JOAQUINCOUNTY. <br />NNNNNNNNNN►ANN NN NNNNNNNNNwNNNNNI <br />NINON NNN NNNNNNNMMOMMOMMMOMNNNNNNN NN' <br />N <br />NNNNNNNwNNNNNNNwNNNNNNNN wNNNNNNNN�NNI <br />Nw <br />NNNNNwNNN <br />NNNNNNNNNNNNNNNN NON NNwwNNNNNNN <br />NNNNNNNNNNN wNNwwNNwN NNNNNNNNNNwNNN� <br />NNNNNNNN�NNNw wNNNNNN NNNNNNNNNwNNN; <br />NNNNNNrYi �1NNwNO .a NNNNNrw wMONO ?riNNwNNN► <br />NNNNN�1►11Y1►1NNNN !Ch!1NNNNNN.NNANNGTCI'►Jht.1NNNNN <br />NNNNNiINYINNNM =[, NNF_y,'nr `LwMM <br />M wNNNNMNNN <br />NNNNNNNNNNNNN�l11�,R11�NN�NNENNN WiNNNNNNNNN <br />NNNNNNNNNNNNMMMIMI r"wNNN NN NNNNNwwwMMMNNN <br />NNNNNNNNNNNNNNNNNNNNNN�N'r.•i NwN NNN NNNNNw[iL►.lE�'iirNNNNNN <br />NNN NNNw�IrJ1JNN NNNNNYwN1IR.MMNNNN <br />wwNNNNNNww NN 10111 ASM 0 �.N. wNltllllr.'It�111►f:?�'rt��lllmom <br />N <br />NNNNNNNNwN� NNNN�11i MMM NN�MMMMMNr?�@:tN11 N>i.1i�.CdltiMM N <br />mom =Mom <br />NNNNNNNN NNNMMEMNENNNNON MM M <br />� ONNNNNNNoN <br />NwNNNNNNNNNNNNwENNNN� NNNN NNNNNNNNN� <br />NwNNNNNwwNNNNNNJ,NNN NNNNNN NNNNNNNN <br />wwNwNNww M. -M 'InNNNURNINNnNNN/YNN NNNNNNNN N <br />NNNNNNN NNl•tlCu]law m�y�i[y!/.1w1�!iSrtZ.Tf,NNNNNNwNNNNNo <br />NNNNNNN NN NNNNN NNNNNN NN NNNNwNNN= <br />NNNNNNN NN NNNNN NNNNCwwMNN NNNNNN <br />NNNNNNN NNN NNNN NNNNNNNNNwNN�NNNNNN <br />NNNN NNNNNNN NNNNNN wONwNNNNNwNNN <br />NNwwww/NwN <br />DEPARTMENT USE ONLY <br />r D. <br />l✓.� ' <br />Date Pump Inspected B� <br />Des iOn _ r <br />001 11001000100 <br />