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r J <br /> nrrvunrrum run IER.. <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SL„-ICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 381, 446 N. SAN JOAQUIN IT, STOCKTON, CA 06201-3 B <br /> (2001 443-MO <br /> NOR-RE VIIIP"tE PEANUT EXPIRES I TEAq R9M QATE 184UE0 <br /> goo"lsfa is Trrllestsl <br /> Application is here by made to the San Joequln Canty for a perrsit to construct "/or Install th work described. This application is <br /> end* In coepllence with Can Joaquin County Development Title, Chapter 9-1115.3 and the Standar of San Joaquin Canty Public Health <br /> Servicea, Envirarsasntal Health Division. rr nn <br /> I.(n0C4I COf'Pir�lT/oy _ L(N10h 15i7H.L <br /> Job Address/or APwr9004 Hookrd City STockT—ova Parcel s(2e/APws <br /> Owner's NaxWTo R C t1 0 P E RATING, Co. Address A�Cl 5 fn(4V Qom. Sun le 1Lq CA 83455 phone ■ (8l )139-4!!I <br /> EMSK C. "'11tr"! � incl`/Hf 1220 idt 4aAS S <br /> [ontrector .f � Eo-t Address Ci//a� cq• 9Spio L{cf + Phone i$o 36B-377S <br /> TAAAIS 6Lo8AL y37- AJ. Cedr-os A,L I 6l0r <br /> Sub Contractor 4EoCNE,y157-R) GTE _ Address 5 oleKa 8egc4 , CA 9107S-Lic,Y_ Phone 0 793-o4'nj <br /> 1 <br /> TYPE OF WELL/NMt U MEW WELL 0 REPLACEMENT WELL U MONITORING WELL R OTHER soil V1P0r U'r �P To <br /> 0 OR <br /> DESTRUCTION 0 OUT-Of-SERVICE WELL 0 CEOPNYSICAL WELL / �[ SOIL BORING µP 7b Ll L.;,,, /101 <br /> �1 <br /> 0 INSTALLATION 0 WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR 11 VAPOR EXTRACTION WELL R <br /> 0 Mew 0 Repair M.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OP PUIW) <br /> INTENDED MUN TYI'!OF WELL CQRSTRU09N XPU lif GTIONS u o 7- <br /> 0 INDt1STRiAL 0 OPEN BOTICN DiA. OF WELL EXCAVATION 1-2- DIA. OF CONDUCTOR CASING Ar,-11; Ole <br /> II DCTIESTIC/DRIVATB 0 GRAVEL PACX/SIZE TYPE OF CASINC/STEEL/PVC AJI,4 DIA. OF WELL CASING Alar b6 <br /> 0 PUBLIC/MUNICIPAL (I DRIVEN DEPTH Of GROUT SEAL TD Ta 5c-r-'�6--SPE FICATION <br /> 0 IRRIGATIOM/AO 0 OTHER GROUT SEAL INSTALLED BT TE,!:� CACUIT BRAND MAKE Porrlt y( /U«-Ce -�c.cT <br /> MONITORING GROUT SEAL PLWED: 0 Yea ). No CONCRETE PEDESTAL BY DRILLER: 0 Yes �f No <br /> APPROX. DEPTH 10 �-T- or leSS LOCKING CHESTER Box/STOVE PIPE , <br /> "ROPOZED CONlTHUCTiOWDINIUNO METHOD: ILO ROTARY_ AIR ROTARY_ AUGER CABLE_ OTHER 9.drg1ti11G - PusL LA—Sri f <br /> G�oProbc J <br /> I hereby certify that 1 have prepared this applicstlon and that the work will be done in accordance with Sart Joaquin County Ordinances, <br /> State Laws, end Rules and Regulation of the San Joaquin County. Home owner or llcsnaad agent's ofgnature certifies the following- "I <br /> certify that in the performanca of the work for which this permit Is issued, I shall not employ per subject to WORKKAN'S CCHPENSATION <br /> Laws of California." Contractor's hiring or sub-contracting signature certifies the following: " t certify that in the perfonaance i <br /> of the work for which this permit is Issued, i shell urploy persons subject to WORg1AN'S COIPENSAT ON Laws of California." THEA"LICAIIT <br /> RUST CALL 24 HOURS IN ACYAN"F a ALL REODIREO INSPECTIONS AT(2011 44M­MJ. Conplete drawing at lower area provided. <br /> Signed X <br /> Title Data iC!' 5- <br /> PLOT PLAN (Drew to Scale) Scale " to <br /> 1- Mynas of streets or roads nearest to or bounding the property_ Location Of house sewage disposal system or <br /> 2. Outline of the property, giving dirunsions, and North direction. prop-ad 4xpenefon of sewage disposal ■ystmes. <br /> 3. Dimensioned outlines and location of @it 'existing and proposed 5. Location 6f welts within radius of 150 ft- on <br /> structures, intctudlns covered areae ouch as patloe, drivwsyB, the prolty or adjoining property. <br /> and walks. <br /> DEPANTNIBfT USE ONLT <br /> Application Accepted sy ate Area <br /> Crout Inspection Date Punp Inspection NY— Date <br /> Destruction Inspection By, Onto Cosrsents: <br /> ACCOONLY: AID/ FACT <br /> PE CODES FEE INF• AMOUNT R! ED CNECIIMSN I RECEIVED BY DATE , <br /> n PERa1R►SEA>}ICE REQUEST NUMBER INVOICE <br /> I <br />