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14 nrw ranllum run ry-, Zvi— PERMiT SAM JOAQUIN COUNTY PUBLIC HEALTH SERVIM, ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAQUIN IT. STOCKTON, CA 86201-3 8 (200) 408-MO NON-REFlINDABU 011111 IM111E 1 YEAR FROM DATE ISSUED CmWlefs is Ttrlkatsl Application to here by oade to the Son Joaquin Canty for a permit to construct and/or Install th work described. This application is sleds In coaplionce with San Joaquin Canty Development Tltle, Chapter 9-1115.3 and the Stender of Son Joaquin County Public health Services, Enviror0ontal Wealth Division. fAhoetl C°ffe!-Orlo l — t4A101I rslyN.Q Job Address/or APN# 9oOq Hoo"r-dt RA City STockTOV1 II Parcel Sits/ADN# Owner's W.ToRct4 OPERATIAJ4 Co. Address-3-34-1 1LVwGv 0r. sk"; E 1(_'t-1 ,ti� Cd (2455 Phone # -233-cilil `j,,,{ 1 22 jJSk Go�StIITiN tl jun in�clo veidt Acq S Contractor f Address G4++i,*rrl1cy CA 93010 Lic# Phone #gam 30A-377r TRANS OL.oQAL E.v111.eouAfF-V74'_ Y32- Al. Cedr-o-r Ave- Sub Contractor fa Eo cNE,ai TRY CTEcS) Address 5 ole•fet T3e-4ch �, CA 91"-7f LIC# I Phone #bt5793-o4c1 J TYPE OF WELL/PUMPS U MEW WELL (] REPLACEMENT WELL U MONITORING WELL # XOTHER Svil Vgfoor PrDlOc��To to [I DESTRUCTION (I OUT•Of-SERViCE WELL D GEOPHYSICAL WELL R SOIL BORING -P 7a (] INSTALLATION U WELL SYSTEM REPAIR U CROSSCONNECT REPAIR (I VAPOR EXTRACTION WELL # U New (I Repair H.P. DEPTH PUMP SET FT. FiRST WATER LEVEL (TYPE Of PUMP) INTENDED USF TYP!OF WILL WIBTRUCTION SPECIfaTiONS A)n 7- Q U INDUSTRIAL 0 OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING .4/,,1";461-[ Q DOMESTIC/PRiVATH 11 GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC �l'� DIA. OF WELL CASING A), A",1ic,£lG 0 PUBLIC/MUNICIPAL ❑ DRIVEN DEPTH Of GROUT SEAL T D ro 5A 01« SPECIFICATION U IRRIGATION/AO U OTHER GROUT SEAL INSTALLED BY TEG GROUTBRAND NAMEt,e7- MONITORING GROUT SEAL PUMPED: L] Yeo )( No COMCRETE PEDESTAL BY DRILLER: O Yes No APPROX. DEPTH 10 4-7 e r- e 5 LOCKING CHESTER BOX/STOVE PIPE 'ROPOAED CONSTRUCTIONIDR11UN0 METHOD: MUD ROTARY_ AIR ROTARY_ AUGER, CABLE_ OTHER y e1 rq u i i L - Qu5 u 5t rl f e'7e obc J I hereby certify that 1 have prepared this application and that the work will be done in accordance with Sen Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin County. Moan owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not aeploy per ono subject to WORKMAN'S COMPENSATION Laws of California." Contractor's hiring or subcontracting signature certifies the following: " I certify that in the perforwence of the work for which this permit is issued, I shell septoy persons subject to WORKMAM'S COMPENSAi ON Laws of California." THE APPLICANT m MUST CALL 24 HOURS IN AOVANC!Fql ALL AEODIRlS INSPECTIONS AT(20111 448-2422. Complete drawing at lower area provided. Signed X /L M3 )44 Title Dete/s 1 PLOT PLAN (Draw to Scale) Scale " to 1. Maws of streets or roads nearest to or bounding the property. G. Location of house swage disposal system or 2. Outline of the property, giving d(wnsions and North direction. proposed expansion of swage disposal systems. 3. Dimensioned outlines and location of all existing and proposed 5. Location of watts within radius of 150 ft. on structures, including covered areae such as patios, driveways, the property or adjoining property. and walks. i imumm 4 L— I+ DEPARTMENT UAE DNIT Application Accepted Sy ate Area Grout Inspection Oy Data Puny inspection ay Dais Destruction Inspection By Oats Comments: ACCDUWNN ONLY: AID/ FAC# PE CODES FEE INFO AMOUNT A! EO CNE"CASH RECEIVED BY DATE PERMTTIBERVICE AEOUlST NUMBER INVOICE OCT-10-1995 14 54