|
NOV-11-1999 13:07 MOORMAN'S WATER x'.02
<br /> CE US -, _.�...---. .,
<br /> E: . . ..,. 1601 F Naie : �,Av .:�,&i;oickton ' ;A 0"05 _,: Permit Noir 16, 3
<br /> fee 8
<br /> :4,::,;�y, Date. ..Is.suedl,.29.7f'
<br /> -'AP 9,F R; LL' CONSTRUCTION �pU0; PERMIT _.:•
<br /> .�'..i�h+:Z' V•. J �3• *0.33:
<br /> Tfi 3; et7ai E res :.1: ear-rorrt ate ' sued�:�;;{,. ;
<br /> e e. n. r, :p tate•
<br /> :c.' :. Ur ..�i?• t191t::' 1'c; •�,;.0. _.�.� :.i :,'J. •`;,'.- y,1::' :� .i. '•:.i':1:� •1: ::
<br /> pplica,�tion is hereby. matt- tor.the San 'Jo qu�6v octal• HeAl.th Di'st,r ;t: fvrz-a permitato destruct
<br /> nom'�+�"DtW-1G thetW*f,V*' fri desc fi e� $w't� � PLlmti.oni i�:made; i :�eomp a.aflce=.w.iirti�:`Sa�: :.
<br /> oaqui.n Cotimly�Orc ,nic Pl �?;X862--$ad 0 q J9. ldi:
<br /> ... .0 .� d;::Regu�ati ns'of.�. - . Sae.; a- q :i:oral::Ileal th
<br /> i st_ x`.i :
<br /> KAC�1:''S7Rf A .. �?•. a - c': ...:tl? :'.�i .:_s's. : ,.� T. 0
<br /> ovner's! Name Phone
<br /> ontractor's Name 1 License# Phone,�f 3 Z a _
<br /> S CERTIFICATE OF WORMAN'S• COl1PENSATIOm! I:fISU 'ICE ON FILE WITH SJLHD? YES- Lam. NO
<br /> YPE OF WORK (Check) : NEW..WELL� DEE .ENO RECONDITION ❑ . DESTRUCTION❑
<br /> �JELC' CHLORINATION L]' WELL ABANDONMENT.❑- , OTHER❑
<br /> :PUMP Ii�STAIL ATI Q ': .UMP.,.REPAIR E3: ,!'* PUMP.REPLACEMENT CI
<br /> "f='�
<br /> I STANCE TO NEAREST E TC;TAfi1K r - WER L3 lES1 IT' PRIVY,-..",.'
<br /> PRSOISP S O SEEPAGE 31 ' ',f$THER _ r
<br /> RTY 'LhN VAT-r- ESTIC WELL PUBLIC.-DOMESTIC WELL
<br /> .INTENDED USE ' TYPE OF. ELL ' CONSTRUCTION SPECIFICATIONS
<br /> n ustr a e�;
<br /> Tool Dia. of'We Excavat on / H
<br /> domestic/private_ --•.. .lad Dia. of::Well Casing '� 4-
<br /> or 6/pubh.i c ��`. YDr. w� Gauge or Casing s �-
<br /> Irri gati on; fi._,,. r , P Depth,---of Grout SeA'
<br /> Cathodic F #ecti ori Ro ''� ' r Type of Grout
<br /> format. ,on.
<br /> Di sposal Other; - '
<br /> _777-:GeopHysi cal. Surface `Seal Inst
<br /> a° e
<br /> UNlP I•NSTALLATiON, C:o rtr•a:ctor '
<br /> `Type: of Pump
<br /> UMP.'*REPLACEMENT: ❑St e.�lork Aqn{
<br /> UMP: REPAIR: ' ° CDs tate•�Jork Dot
<br /> ESTRl3CTI0N OF,WELL. ?k .,Weill Diameter ' Approximate Depth
<br /> I } scribe Maters a�n� rocQ ureAw
<br /> r
<br /> •. ''v. ;
<br /> hereby certify that I :_h ve prepared:; th,+is appl icatio' :and' that.the- work will be-. done in accordar
<br /> i th. San. Joa. u n ,County..0,,rdintnces .!Staff airs,; and; R l es 'and-' Regufiations :of `the San Joaquin Loci
<br /> ealth Districir Home:.owner-•-or •licensed' aggena'sr.signiature;certifies the following:
<br /> "I certify that in°tbekperformancei piJ�:tf�e work: for, which this permit. is issued, I shall
<br /> p y' y person' in such ma'i��1e. . as,to become! .subject to Workman's Compensation
<br /> not em 10 : an r�
<br /> laws of Ca^Iforn a:" ;:: :
<br /> WILL CA FOR A°- :d.HSR CTION PR1OR�'��o-.-�G�?OUTING AND. A:'Ffi AL INSPECTION-.
<br /> s DATE: ,!l �-
<br /> ;..
<br /> ME ONL
<br /> RASE '.I`. .. :_ . . • •.a }•�.o. `�ti *`� '.0 •.�`�.'; '' , •'' .. . '
<br /> I >T-=IOR'ACCE•PTEi $l�`• ' 'r y _. DATE
<br /> LSD IT I� A E1VTS.��'�°. ::•-+r.;�`��: ��';:. : : .�:>:�_ _. .: : . . : •. ,
<br /> PNASE'i PHASE: II'i FINAL INSPECTION
<br /> =
<br /> NSPECTION BY DATE '' INSPECTION BY DATE
<br /> 1 1'7 Q 71J.
<br />
|