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3� r'S APPLICATION FOR WtLLIPIIMP PERMIT SAN JOAQUIN COUNTY PUBLIC 4EALTH SERVICES ENVIRONMENTAL HEALTF DIVISION P.O. BOX 388, 304 EAST WEBER AVEN E. STOCKMN. CA Vml- 86 (2091469-3420 NOR-REFUNDAHE PERMIT EXPIRES f YE IR FROM DATE ISSUED (Complete IR TrkRe$e1 APPLICATION IS HERE BY MADE TO THE SAN JOAOUfN COUNTY FOR A PERMIT TO CONSTRUCT.AND/OR f STALL THE WORK DESCRIBED.THIN APPLICATION 16 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAOUIN C NTY PUBUC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOS ADDRESSOR APN1 ��'// �j�-O 8 /f �j,�C? 6• UP;-, S-t D crry ,LO�Ij _- I /YeT�S �/1' UIT J PARCEL 9♦1TElAPNI ADDRESS 91r/_a.-7 .L.d/}/ ✓ al�/ PHONE OWNER'S NAME �/ CONTRACTOR.. V -A t�l,At? 1�41 N�Y: L��b _.. ADDRESS, i I UC/ 76ta 70 PHONE SUB CONTRACTOR ADDRESS J �� Ctj /M-7-/UC1 PHONE( TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WE 1 ❑OTHER - ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL t ,/ ❑ ITYPE OF 1•UMpi Now 11P.,.k H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL p ' ,I ❑ OUT-Or-SERVICE WELL ❑ GEOPHYSICAL WIN 1 1 SOIL BORING g ❑DESTRUCTION: INTENDED USE TYPE OF WELL, CONSTAUCTIOH SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA,OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACKMUZE TYPE OF CASINGISTEELMVC D1A.OF WELL CASINO D ❑ PUBUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION p ❑ fRR1OAT10NIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME_ e ❑ MONITORING GROUT SEAL PUMPED: ❑Yee He CONCRETE PEDESTAL BY DRILLER:❑Yae ❑No S APPROX.DEPTH LOCtl( CHESTER SO 7--� - VE PGE S PROPOSED CONBTRUCTIONIORBLUNG METHOD: MUD ROTARY AIR ROTARY CABLE OTHER I HMOY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAOUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLO%fNG:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS O CALIFORNIA.' CONTRACTOR'S HIRING OR SLUB.CONTRACTING SIGNATURE CERTIFIES THE FOLLOW HM 'T CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH TWO PERMrT IS IB ED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPUCAHT MUS CALL 24 HOUR$IN ADVANCE FOR ALL.NFUMBED INSPECTIONS AT 11091 4443122. COMP!ETE DRAWING AT LOWER AREA PROVID J Sloped X rA01,1 TItle '� O OHs :..... ' - 2; P4 ti. TI SL;C. . r DEPARTMENT USE ONLY - 43�AAPllaatlen Aee"Hod By Ome L 6l-Le>r��Mw �.1LLd - allUA Oteut Irnpeetlen By Dote Pu P ImDe dan By r L Date Deetnwden to* to BY "��✓ Oate /C � ^ Comments: I�rIF, ACCOUNTING ONLY: AIDS FACT PE CODES FEE INFO AMOUNT RENUTTED 1E ASN RECEIVED NY DATE PERMITI$EHVICE REDUEAT NUMO6e INVOICE .(.,;0 C2 ba 5 "ice l5 r Pub.Heaith Serv.-EnvirD.173(3196)