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WRLO <br /> �Alll JOAQUIN COUNT'Ptlp ~ ^- <br /> TR lE11VR� <br /> ENVNBONNIENTAL REALTR DIVISION <br /> P O BOX 801, 446 N. SAN JOAQUIN ST, STOCKTON, CA 16201.310 <br /> RON 401.3420 <br /> FUNDABLE PEW AMM 1 YEAR FM DATE IMED <br /> iCaagtMla <br /> In TrWaalsl <br /> Application is here by erode 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 Canty Public Nealth <br /> Services, Environmental Health Division!. <br /> Job Address/or AP14#07-4.2i r r-Q eDte�eJ City 1 Parcel Size/APNN <br /> Owner's Name - E <br /> Addrsas Phone #Jgl K7 --l(v w <br /> Contractor Address Lie# PhoneT`l,`°'ay <br /> l i &A/, <br /> Sub Contraetor�en 1 1 Address .�b9�• j <br /> Phone 0� <br /> TYPE OF WELL/PUMP: WIM WELL p REPLACEMENT WELL WIMSITORiNe WELL # 0 OTHER <br /> E1 DESTRUCTION 11 OUT-OF-SERVICE WELL 11 GEOPHYSICAL WELL # 0,161L BORING <br /> U INSTALLATION E] WELL SYSTEM REPAIR [I CROSS-CONNECT REPAIR E] VAPOR EXTRACTION WELL # <br /> (TYPE OF PIMP) [1 New [1 Repair H.P. DEPTH PUMP SET T. FIRST WATER LEVEL <br /> NITERi®USE TYPE OF WELL <br /> El INDUSTRIAL [1 OPEN BOTTOM DIA. OF WELL EXCAVATION i� DIA. OF CONIX CTOR CASING <br /> L1 DOMESTIC/PRIVATE E1 GRAVEL PACK/SIZE TYPE OF CASING/STEE DIA. OF WELL CASING 4L <br /> l7 PUBLIC/NUNICIPAL E1 DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> [1 IRRIGATION/AG E1 OTHER GROUT SEAL INSTALLED BT j2*L %t&d- GROUT BRAID NAME <br /> 61�}�NITORING / GROUT SEAL PUMPED: G Yes 0 No CONCRETE PEDESTAL BY DRILLER: MoOTis 13 No <br /> APPROIL LOCKING CHESTER BOX/STOVE PIPE <br /> PII MED CONITIDICTIONIO NLWO METHOD: MW ROTARY AIR ROTARY AUGER✓ CABLE OTHER_ <br /> I hereby certify that I have prepared this application and that the work will be done in accordenei with San Joaquin Canty"renes, <br /> State Laws, and Rules and Regulations of the San Joaquin County. Home owner or licensed agent's signature certifies the foltoWn0: "I <br /> certify that in the performance of the work for which this permit is issued, I shall not employ persons subject to uORIOWOI'$CMUSATION <br /> Laws of California." Contractor's hiring or sub-contracting signature certifies the foLLowing: " I certify that in the <br /> of the work for which this permit is issued, I shall employ persons subject to WORKMAN'S COMPENSATION Laws of Cstifornia." THE <br /> MIT CALL 24 HOURS!NI AOYANCE FON ALL NEOVAIED NIt lWnONi AT 088)4BB-3423. Complete drawing at Lower area provided. �r <br /> Signed X LA?22A2-� a Title_ ��woGac46"f Date fit` <br /> • <br /> DEPART. MEITUSEONLY q g <br /> Application Accepted ey, Date ` �` Area <br /> Grant Inspection By Date Pump Inspection By Date <br /> Destruction Inspection By Date Comments: <br /> ACOODITIMS ONLY: AID# FAC# <br /> PE COMM FEE INFO AMOUNT REMITTED CNECK9=811 RAYED BY DATE PERMRISERi110E WSWIST Nunn WON <br /> _0 s <br />