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FROM 01/04/95 10: 24 P. 2 <br /> APPLICATION FOR WELiaPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTN SERYIC <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 SOX 388, 441 N.SAN JOAQUIN ST,. STOCKTON,CA 95201-318 <br /> (2091 419-3420 <br /> .wr.m11111A ,E x■NNT E MALS i VAN F M DATE 1Ei1UED <br /> 94101110410 in Tf*IWW <br /> Application is here by vada to the San Joaquin County toTitleea, Chapter 9 1115 3 end the Statt -id/or ndards t <br /> fum is <br /> andarda f Saw Joh�y Publlctleelth <br /> meds in Compliance with son Joaquin County Developaen <br /> Services, Ertytllawaental Health Division. <br /> 3437 South Airport Cit, Stockton L Sit.IAPNMs <br /> Job Address/or APiiill C5 Pirenwe 04 <br /> Applied Aerospace Compos Corp. same (216 586- 980 <br /> OwrMr�a Noma <br /> McLaren/Hart Env. Eng. raeuA9 1hl 6'19--3696 <br /> Contractor Tracer ResearchCorp. Address or <br /> h doSrr <br /> va A Y P'a '� 9 •899 -9400 <br /> sub ContraetorM <br /> TYPE OF.IIELLL� (INEW YELL a REPLACEMENT YELL 't1 MONITORING WELL 0_,,_, 41 Soil Vapor Survey <br /> p DESTRUCTION 0 WT-OF-SERVICE WELL a GEOPHYSICAL WELL D SOIL DURING _f�$b water <br /> 0 INSTALLATION 0 YELL SYSTEM REPAIR a cRoss-CONNECT REPAIR a VAPOR EKTRACTIDM W-LL O—epefnples <br /> p New 13 Repair N.P. DEPTH PUMP SET_ - FT. FIRST TATER LEVEL <br /> (TYPE Of KW) <br /> WOOED TYPE OF TfELL <br /> DIA. OF WELL EXCAVATION DIA. F CoiquctoR CASING <br /> p 1MRNJSTRIAL 0 OPEN BOTTOM DIA. F WELL CASING0 DOMiiSTIC/PRIVATE U cIUYEL PACK/8128 TYPE OF CASI11G/STE%/PVC��� <br /> DEPTH OF GROUT SEAL 3PECI ICATION <br /> 0 PUBLICf"ICIPAL 13 DRIVEN GR BRAND MAME <br /> a IRRIGATION/AG 0 OTHER AW SEAL INSTALLED 4T <br /> MONITORING GROUT SEAL PUMPED: 0 Yes 0 No CONCR TE PEDESTAL BY DRILLER: (I Yes (I No <br /> APP80X•DrTIi 6��50 LOCKING CHESTER SOK/STWE PIPE it <br /> �ROPOSED CONSTRUenOsi110RILLINO METHOD: M1RM ROTART_ AIR ROTARY_AUGER_CA LE_ OTNE sh" type rig <br /> ' 505:. <br /> red this app ieation and that the work Witt be dons in occo Math Sen Joaquin Canty Ord as, <br /> I hereby *artily that I have prapa Nome owner or Licensed •pant's ignaturo certifies the following! Of <br /> state Lon, and Rules and Regulations of the sen Joaquin County. t g,bj�to-wORKIYAM"S COMPENSATION <br /> certify that in the psrfOMMme of the work for which this permit is issued, i shall not employ per <br /> Laws of California.* Contractor's hiring or subcontracting signature certifies the following: e T certify that in the performrnce <br /> of the work for which this permit is issued, l shall uaploy persons subject to WORKMAN'S COMPENSAT ON Laws of M9lifornia" BNB AIMIIGOi <br /> MUST CALL 14 1409WILM ADVANN F08 SE RUM INDPi; MNS AT DMSI 480,342=. Complete drawing at tow ir area provided;0, <br /> X Title <br /> signed <br /> PLOT PLAN (Draw to $oale) Scole a to __ <br /> 4. Location house tawass disposal system or <br /> 1. Names of street! or roads nearest to or bounding the property. ion of•ewgo disposaL system. <br /> Z. outtine of the property+ giving dimensions and North direction. 5. Location f welts witi<in radius of 150 ft. on <br /> 3. Dimensioned outlines and location <br /> W are" such asltpatiios,patios,mid driveways, the or adjoisyisN property- <br /> oposed <br /> strturq, Includingcovered <br /> and walks. <br /> USE <br /> Application Accepted N <br /> GroAit ltlsp•ctiuxu BY <br /> �( Data�5116'42_5,Pump inspection By_ Oath_ <br /> Destruction Inspection 8y Date Commants• <br /> AMUWff MS 0NIY: AID# FACN <br /> /R COOEt FEE INFO A1110119f REIMifTEN CN'CKXCUV REIMIYED By BATE POWISEN I VICE UMW UNIX RI"Mi <br />