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nrru%.nnmuw rvn w,.. rv...r4TERMIT <br /> SAN JOAQUIN COUMTY PUBLIC HEALTH SEI .8 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 318, 446 N. SAN JOAQUIN ST, STOCKTON, CA 16201-318 <br /> 208) 482-MO <br /> • NOR•REFURDAR(E PERMIT UP111E3 i YEAR FROM DATE IS8UED <br /> iCsglels is T►iplimis) <br /> Application is here by made to the son Joaquin County for a permit to construct and/or instatl the work described. This application is <br /> wade in cospliance with tan Joaquin County Development Title, Chapter 9-1115.3 end the Standaof San Joaquin County Public Health <br /> Services, Envirafspentat Maalth Division - rr nn <br /> ml.toC41 Cof-f-ra_rlorl — Li"!O•-t 1Sl�NK <br /> Job Address/or APWN 9009 Hz o trd. fZaQ City STockroyW Parcel Size/APwr <br /> Dwner'R Mma lciRr-14 OPERA-rltJ4 Co, Address39C'l C�'. <,;k 1044 CA 4'3455 Phone . <br /> /JSR (T <br /> GortsuiyV viss 122o ve mdt AaAS <br /> Contractor E � f f2lI"`�rlAddress C4."ari//a , C A 930i0 Licr I Phone 0 38B-377 - <br /> TRAMS 6LzdAL E,jv1,eoa0fE,v744- y32 -. Gedro.s Ave 6/5 <br /> Sub Contractor L4BoCiIE/l15r9 ' ETES) Address 5 ele.r4 13--,9c4 , CA 92o7SLicg I Phone 0 793-ozzo] <br /> TTPE OF WELL/PUMP: U MEW WELL 0 REPLACEMENT WELL 0 MONITORING WELL mK I OTHER Soil V�Por � <pTo <br /> to- <br /> ❑ DESTRUCTION ❑ OUT-OF-SMICE WELL 0 GEOPHYSICAL WELL IF SOiL BORIHG wP 7b 44 <br /> 0 INSTALLATION ❑ WELL SYSTEM REPAIR 0 CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL K <br /> 0 New 0 Repair M.P. DEPTH PUMP SET FT- FIRST WATER LEVEL <br /> (TYPE Of PMP) <br /> INTENDED USE Tttt OF WILL WISTRUCTTON SPEC I!F GTIONS <br /> C] INDUSTRIAL 0 OPEN POTION DIA. OF WELL EXCAVATION l-Z i ne4tS DIA. OF CONDUCTOR CASING <br /> 0 DCM9STiC/PRIVAT3 0 GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC W14 DIA. OF WELL CASING Al-r <br /> U PUBLIC/MUNICIPAL 0 DRIVEN DEPTH Of GROUT SEAL TD -r- Sur4e, SPECIFICATION <br /> [] IRRIGATION/AO ❑ OTHER GROUT SEAL INSTALLED BY 7E a0`1,T BRAND NAME p°-ria-,s( <br /> I <br /> MONITORING GROUT SEAL PIMPED: (] Yes ). Mo CONCRETE PEDESTAL BY DRILLER: (] Yes X No <br /> APPROX.DEPTH l0 trT or I eSS LOCKING CHESTER BOX/STOVE PIPE � <br /> "ROPOBED CONSTRUCTiONIDOILURg METHOD* NLA ROTARY_ AIR ROTARY_ AUGER, CABLEOTHER �}yclr9KimG - P SI, Lt Sr H� <br /> G�opro6 <br /> I hereby certify that i have prepared this application and that the work will be dor* ,n accordance with San Joaquin County Ordinances, <br /> State Laws, and Rules and Rayuistions of the San Joaquin County. Moan owner or Licensed agent,9 Isignsture certifies the following: "I <br /> certify that in the performance of the work for which this permit is issued, i shall not employ persons subject to WORKMAN/S COMPENSATION <br /> Laws of California." Contractor's hiring or sub-contracting signature certifies the fotlowing:l » I certify that in the parforwence <br /> of the work for which this permit Is issued, I shall awploy person subject to WORKNAN,S COMPENSATION Laws of California." THE APPLICANT <br /> NUST CALL 24 HOURS IM ADVANC!P a A.L-L AMINES INSPECTIONS AT 2011440-2423. Complete drawing at lower area provided_ <br /> Signed X w' Title f i�'�l/Yi�Q Date lC� IS <br /> PLOT PLAN (Draw to Scale) Scat& " to <br /> 1. Msoms of streets or roads nearest to or bounding the property. G. Location of house swage disposal system or <br /> 2. Outline of the property, giving dieansiom and North direction- proposed expansion of sewage disposal system. <br /> 3. Dimensioned outlines and location of all 'existing and proposed 5. Location of wells within radius of 150 ft- on <br /> structures, including Covered are" such ea patios, drivwayR, the propefty or adjoining property- <br /> and *elks. <br /> DEPARTMENT USE OMIT <br /> Application Accepted 0y Data Area <br /> Grout Inspection gY Date Pump Inspection By I Date <br /> Destruction inspection Sy Date Cowsents: <br /> ACCDURTIRg DRIy: AIDE FACT <br /> PE COOL FEE INFO AMWNT R! ED CNECI(JUSH SECHVED BY GATE PERWTISEMCE REautIT NUMNER INVOICE <br /> 1 �1 ;V1 / ti R1ti �� <br /> OCT-10-1995 14:54 <br />