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APPLICAJIUM itUK WtWrwmr rr-2-41 � <br /> Safe jOAOUlN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISIONl11.�� f <br /> P 0 BOX 38& 445 IL SAN�JO 411111 2tIfel rSTOCXTOX. CA 35202388 !�, : aH� <br /> O4 ` <br /> o r �"� A�ria <br />' MOR RJ:ONDA8t9 PERMIT E MRE3 t YEAR FROf9DATE iSWIM <br /> r- <br /> witphrte a Trviicato P <br /> "Lzcateon is here by made to the San Joaquin Carty `or a permit to contstnuct and/or instal[ the work described. This aU.0 is <br /> made in comtiance with San Joaquin Carty Deve qmwnt Tltte, Chapter 9-1115.3 and the Standards of San Joaquin County PubLic Lth <br />' Servtees, :frvirmoental Health Division. <br /> 5400 Pacific Av Stockton <br /> Job AdcrMxs/or AANs City Parcel SrYelAPNa! <br /> cwner,s Name Montgomery Ward& Co, inc Address 39201 Fremont Blvd Fremont, CA 94538 Phone ;g 5101794-2277 <br /> Contractor V&W Drilling Aderdss P 0 Box 51, Rio Vista CA Lig_f58786 PI4IX7e $ 916/631-7165 <br /> Sub Contractor n/a Address Ltc13 Phone !t <br />' Tyef OF WELL/P MP• el NEW WELL E7 pF_--_ACE SVT WELL ri MONITORING WELL f 3,4,55 &6 I] OTHER <br /> p DESTRUCTION p WT-OF-SERVICE WELL 13 GEOPHYSICAL WELL * 0 SOIL BORING <br /> Q INSTALLATION lI YaL Sy5TE3M RUAIR Cl CROSS-CCNMECT REPAIR I] VAPOR EXTRACTION VCLL d <br />' IJ Iles+ p Repatr if-P. DEPTH PUMP SET FT. FIRST WATER LCL <br /> (TYPE OF PUMP) <br /> WENVEn OSE TjpE OF WELL COMSTRUCTiOR SPECIFICATIONS <br /> (7 INDUSTRIAL L3 OPEN &OTTOH OIA. OF %XLL EXCAVATION 11" DIA_ OF CCWUCTOa CASING n/a O <br /> C3 DoKESTIc/PRIVATE V GRAVEL PAMISIZE TYPE OF CASING/STEEL/PVC PVC SCh 40 DIA. OF WELL CASING 4" ID Q <br /> 0 PU8LICIMMICIPAL p DRIVEL OF--TH OF GROUT SEAL Aoorox a8' SPECIFICATION PVC Sch 40 <br /> 13 IRRIGATION/AG 11 OTHER GRCUT S'c-PAL INSTALLED ST V&W Drilling-- GxOUT BRAID NAME Portland Type Il <br />' 13 iMOHITORIXG G20JT SEAL PUMPED- Ct Yes 0 Mo =CRETE PEDESTAL SY DRILLER: ❑ Tel a Mo <br /> APPROX.DSrM 70' c=THG CHESTIR SOX/STOVE PIPE Christy BOX <br /> PROPOSED =STIiUCTlOWDRIWNG 1(J: HOO HUD R(TrAAT__ AIR ROTARY, A=R X C ZLE�^ OTSE:t <br /> WW- I eterew certity that I have prepared this coat cation and that the work wiLL be done in accordance with San Jeaqutn County QrGltlaflCYS, {1 <br /> State Laws, and aisles and Regutations of the Sari Joaquin County. Home owner or Licensed agent's signature certifies the foltOwtng- <br /> certify that fn the perTormmJ'Lee of the work Tor Whir" L'Ita petnclt is 1M.-ad, I shall rat em(cry persons Subject to WORKMAN'S CJtPc�SATION <br /> Caws of California." Contractor's hirting or raa-cant-acting signature certifies the following: " I cert-ify that in :he perrormvxe <br /> o: tune .crt for w4ich this perms: is isased, 1 ; 4tt emley persans SUbiect to L7 104AN'S CONPEl.SATION tarts o` CaLtforrlla THE APPLIC3)CT <br /> MUST GALL 24 HDUM IN AOVAIICE FNI- UIRED MWEMOXS AT(2091468-3423. ComoLete drawing at loser area provided. 4 <br /> 01 <br /> Steven A Bright Tale Presiden Data 1/10/1995 <br /> S,gzed X <br /> I <br /> 14+1 <br /> DEP1lRTiliERT USE D11L7 <br />' AmpLiration ACCepted ey Date /C� _ Area <br /> Grout Inspection 3y Date imp Inspection 3 'wDate <br />' Destruction inspection 3y Date Cocments: <br /> ACCnUMTAIs UXLY., AID:3 FACS JF <br />' PE CODES FEE INFO I AMOUNT REMITTED I CHECICf=Sx RECSYEB HY kDATEMI PERTISERVICS AEDUEST 1ri11 SER iNVOICE! /Z 9s D <br /> 6L- <br /> C-Opy <br /> l <br />