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'. S9.F'�'.�YIY5T iY •. <br /> ik 'k <br /> " — <br /> RADIENT ENVIR 91452 2892 F>. 01 <br /> - 4 <br /> APPLICATION FOR WELLIPbMP Pi RMiT <br /> SAN JOAQiIIAI OuNTY PUBLIC HEALTH SFRVICEZ <br /> ENVIRONMENTAL HEALTH DIVISIDN1 h <br /> P 0 BOX 381L 446 M. IAN JOA110IN ST, STOCK(TON, CA 96201.388 ; <br /> (20i) 468.3420 <br /> NON-AEFUNDABLI PERMIT EXPIRES Y1 0M OA. ISSU ill <br /> � 1 <br /> tpplication is here by made to the San Joaquin Canty for a Permit to construct and/or inststt the work described. This application is <br /> rade in coViiance with San Joaquin County Oevatcpment Titte, Chapter 9.1115.3 and'the Standards of San Joaquin County Public Health <br /> iervicas, Environmental Health Division. <br /> lob Address/gr APN# 90 / V IGTr,fz City o Y?/ Parcel Sfze/APM# <br /> 3wner's Neave TO �l 7-E Rr=' S Y Address fog-,- �. Phone N <br /> F ontractor V¢W 1.>r;?)L c_ t 47- Address 1'o r-^`%�1 I2 V IS 7,91 l die# 6-5 8"7F(o phony <br /> Sub Contractor Address i4 L{co phone M <br /> E TYPC.4K WELL/PUMP- ti NEN HELL p RVLACEMENT WELL 1K MONITORING WELL A p OTHER <br /> TJ OESTRUCTtON q tltit-OF-S@RVIC1: YELL (I GEOPNYSICAL WELL 1t IS SOIL BORING <br /> q INSTALLATION a Wl.t IYSTER R£DA1R 13 CROSS-CONVECT REPAIR p [D VAPOR EXTRACTION WELL N <br /> q New CJ Repair M.P. DEPTH PUMP SE „.SFT. FIRST VATER LEVEL <br /> (TYPE OF PW) <br /> INTENDED TYPE OF WELL CDNSTRUCTION SPECIFTCATI0N5 '� e <br /> (I INDUSTRIAL [I OPEN BOTTOM 01A. OF WELL EXCAVATION �_g" ,i_lo�� DIA. OF MWOUCTOR CASING <br /> 4 [I DOME5TIC/PRiVATti (1 GRAVEL PACYJSt7f TYPE OF CA51NG/STEEL/PVC �c v.-;fvC ; DIA. OF WELL CASING <br /> (I PUULIC/MUNICIPAL a DRIVEN OCPTH OF CRCl1T SEAL Z V V' d! �SPECIFiCAT[OW .OZO SG2cry _zr� <br /> 0 IRRIGATION/Aa q OTHER GROUT SEAL INSTALLED BY_TRrfer j5 IGRCLIT RRANO NAME P6.17-L—e-1 <br /> MONITORING GROUT SEAL PUMPED* <br /> 'K Yes lI No :CONCRETE PEDESTAL BY DRILLER: )S( Yee (I ito <br /> AFF1103.DEPTH 70 LOC%1NC CHESTER BOX/STOVE PiPE i;hf S <br /> PROPOS0 CONSTRUCT101HDRIIJ[110 KFTH00: HUD ROTARY AIR ROTARY_ AUGER CABLE OTHER_ <br /> I hereby certify that I have prepared this application and that the work wikt be done,in accordance with San Joaquin County Ordinances, <br /> State Laws, and RUtes and Regutations of the San Joaquin C*WtY. xome owner or licensed ageitit's signature certifies the. fo((owing: "I <br /> certify that in the Performance of Che work for which this permit is issued, I shall not emptay persons subiect to—WORKMAN'S COMPENSATION <br /> Laws of California." Contractors hiring or sub-contracting signature certifies the followings " I certify that In the performance <br /> of the Mork for which this permit is issued, i 0.3(1 &Mtoy persons subject to WORKMAW3 COMP>HSATION Laws of California." THEAPP€ICANT <br /> MUST CALL 24 NOUR4 IN A E FOR ALL RFO A-UMFESTIONS AT 041 468.7423. Gamptete drawing at lower area provided. <br /> signed X P. i Titit Oaten 5G <br /> DEPARTMENT 931 ONLY <br /> Appkicotion Accepted By F Date Area <br /> 1li � <br /> Grout Inspection By Date Pulp Inspection By Date <br /> i3 <br /> Destruction Inspection By Date Comments: <br /> ACCOUNTING ONLY: AID# FACA <br /> AE CDOES FEE INFO AMOUNT >lE1sITTEll p1EC7[fiCASA RECEIVED BY DATE P01:1111111 Vitt REQUEST NUMBER INVOICF <br /> iF <br /> �� ll ti <br />