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+ I Al'YU6AIIUN FUR WELLIPUMP PERMIT - _.....
<br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERtrtts
<br /> ENVIRONMENTAL IIEAL7n DIVISION
<br /> r 0 BOX 3911,444•N.SAN JOADUIN ST.,STOCKTON,CA 96201.388 1
<br /> (209)468.3420
<br /> I� �` i , NON•p[fUNDAOI_ E PEpNIL1fpIR[S tYENN FROM DATE ISSUEII !
<br /> Memphis to Ttylicatel '
<br /> Appticrglon.II hr 1rylalada to t6ti:'son Joaquin County for a permit to construct and/or {nstall the cork descrtbcd. this eppl(eatlan (s
<br /> made-Ip.lcompllarxe!wlth:$an Joaquin County Development Title, Chapter V-1115.3 and the Standar of San
<br /> Servicai, Env1r nta Health oivis(on. Jbe In County I ° qu1 Puhllc Health*
<br /> JobAdil ieii;i/gFAPuX't?l $'• In/.'C[zWer (�o cit ra..G .,#. ..
<br /> I' ' y -Z--- Parcel',$)zi/�PNNi2l4-/So-yz�g3
<br /> '?irieier'�s.iienk i LjloH: 'f� aFr�,ari. bh.; Blvd. D� 11:.6 c p: y'ys-6 e
<br /> Atklreaa !l820 Du
<br /> I'•'' i'' tt, } t Phonj N_SIo�929-899/:
<br /> ,.i;Coritrectpr! f.✓ASeerrah. {rt k„i, 158o N. 9 St. l
<br /> Address Sar. Jaz¢ eq' ' 1
<br /> LIeI '
<br /> fut>coritractob FI'rpii F r• DI-1 MIM' I Phone N 904 4S3-nao
<br /> Adr1ress 173o H-AIN N10rltl Dr, ;
<br /> LIai CS7.671Sv.
<br /> ' !, ,I----•y---, 1 •• �✓ p� __ .y Phontl /800 20!-On8J
<br /> e TYPE`OF IIFIL%PINI"••• ,N W'WEII••.:. .• - 1 1 .
<br /> ` .., ,. •• U REPLACEMENT WELL .
<br /> HQNII0RIN0 WELL 11'
<br /> Ir b'4TRUC11oH:•, OTHER-
<br /> GEOPHYSICAL'{• ''• '' 1•/', x:lXlf-OF-LERVICE•VEILS U GEOPHYSICAL WELL /
<br /> ! SOIL BORING' 4
<br /> • I •I+ ! 1 RIISTALT.AiIOtI 1 (/ELL SYSTEM REPAIR i-4- '
<br /> I }• [1 CROSS-CONNECT REPAIR .
<br /> ,: I., I'•+' [1 VAP • EXTRACTION
<br /> 1i Repair l(�JI\P. WCII A'
<br /> (TYPE OF'PIA{'- p,)� '• •�' _ ,•D�s ro '.,�!, DEPiN PUNA SE1�-fT,• fiRSi tJATFR LEVEL
<br /> IN DITIS r 'i T.” 0.•. L' :,: :•CQI�STRUtTIQN SPECIFJ ONS
<br /> -..'0 INDUSTRIA '
<br /> .,_: 4 II,;O KbCTTOM DIA.;Of.CONOUCT.OR CAStNC p10Np'
<br /> DIA. OF WELL EXCAVATION e i
<br /> Tl•.DONESf(C�PR7yTE:`(IIIq AVEQPACX/SIZE_ ' ,TYRE OF CASING/STEEL/PVC PVG
<br /> • .-TI
<br /> (1 PUBLdC/iMI:ICIF)IL.:)1111111'IC LVEN: . r DIA-.OF WELL CASINR ! 2
<br /> I. ,� DEPTH of GROUT-SEAL 2
<br /> 1 (1 IRRICATION%AC lIQ HER; �---- SP[CIItCAtIONse�1e�. ty P V C
<br /> ,.I l I• ; . . 'GROUT SEAL INSTALLED BY r-'I; ori r [ht//I„'CR ujE •Parfla�
<br /> q1 ORARD N i
<br /> :,,*- 1..: -f I I, 1,• ; •I j ' i• GRgli SERI PIMPEDt
<br /> t
<br /> APPB0X:tl(PFlli U Yes .CONCRETE'PEDESTAL a DR,ILLER: [I Yea''p'No'
<br /> . ',.• II;. O,I•,.il LOCKIND CHESTER BOX/STOVE PIPE_S'IsYe
<br /> bAOPOSEIIiCOMSTRUCT10NjDI iILING METH00;•Nl1D'ROTARYr:AIR.ROTARY-_AUG
<br /> CABLE__bTNER'
<br /> l� I ! ..
<br /> 1 h4rcbylccrtifylIt�at II� ve ptepe're�f It a eppileption end that the work will be dotx In'ebcorderice w th SM,Joa
<br /> 'Stale Levs:a'el;kufeh and Rcgi, tottons,of-the ten'Joaquin'Ceunty- Ilon,e owner or Ilcinsed egenNs's 1
<br /> �i.. . ,. ,• . .''.. .� '.' �ri Coi+nty Ordinaneee,
<br /> •-Mer{,ifyl tKel .tA;llyq f!fflor'';nti:ot.: work foe which-this permit 1's-Issued, I shall.not _1tH»ture eertifles�the loltowtng: "t
<br /> Lawi'.pN'CYlffomiil:;' ,C" vector, 16r -contract.Ing signature certiflee;'no fatlay Pe ps W)ect to.WORKIIAN's towENSATiOR
<br /> !! nring, 9 I 'eertliy that!.Tn,the perfbrmonce.
<br /> I: :pd/Qh Aprk:(oP.w'IicJi`tljis /ehiltt'Is:)ssue4, 1:shell employ persons subject to WORKMAN'S COMPENSATION Laws of,Caltfornls." THE APPLICANT'
<br /> NIJ&T CAII'21'HOU: (tN;j1�YA (E'i ON A'tl:OEOUIREO SPEC IONt AT 11001-4U-3423. Corrptete drawing at totter ares'provlded.
<br /> Sigoed'I
<br /> T1ile SCIJIOR ••GE(S(:061sT' Date)n/
<br /> PLQ..T PLAN (Draw to stole) Scale' ro 0 / RP-ASERitut� INIC,
<br /> I �e �-T" J
<br /> ot.�.tieet•a.'oh1Y}ads':'Ijeerett.to or T,our;diny the'preperty. �,
<br /> ',2. •Dull qe;o'tlje:piopfr `,yt.viip;dilKenstotis tird.+North direction.
<br /> Location of reuse stwagetdisl'Tal'systera'ar
<br /> "1.•:Diia�dioned•6trtl'Ines'�i •tgcaticn of all exlsttnp and prolwsed• Prolwsed:expanslon.oR sewoge d►sposaC systean,'•
<br /> i' I'" " '` S. Location•of wells wtihlit redfus::of•ISO 1t.'on
<br /> Ictructurtis.,"igcliW tg covered•'Ireeds iuch';as,Patlost driveways,
<br /> �.
<br /> 46$- at, '!•� I;;I y l' the-property,or edjol'ning Property'
<br /> i l i i
<br /> 1 I j '0+� F•Jrrrru� � .
<br /> i Ii 7-
<br /> jr - r-w wrrrr.w I i s Wi
<br /> t #a ' liw
<br /> I 1
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<br /> —'i'�� .v.r.+ro,.•r.•rrsrr.w.,ti.r�r+.•rrr+r _�..,......
<br /> IIf I.' ' I•' bEPARTMENT'UtE ONLY
<br /> Acte(i[ed:q
<br /> :, i'.... it; , ,•• Date
<br /> �;,:I. j•
<br /> I: ^.croUi.i)n peii'on By 'LS'. ' Arae
<br /> iI Date Purp lnspectlon By " j
<br /> I' !`Deitfli<t�.6,''Irispe " Date
<br /> I.' I• i rt: c`ti, By. Date 1
<br /> ;A000UNTINO.lop. :ItI AIDI!! .. .
<br /> FACN Q/,
<br /> E...,O -
<br /> '„' '� Jl OUIIT.II talitEH'• •CI,IRKf{CAill' :Rf.CEIY[0 BY GATE
<br /> PEIiMlil4[gVICE.IlE4IlEST'NUMO[R:I INVOI
<br /> 7
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