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-....�-- <br /> EMO11AAENTAL HEALTH 911141E00 <br /> 0 BOX 319.446 N.SAN JOAQUiN OT.STOCNTOR,CA!ir W <br /> L 2011 4664M \1.0/ <br /> NOWIM11011 POW EX M 1 TEAA FMN OATS 111t9 <br /> caegbM Y TrlPNsao <br /> Application Is here by made to the fan Joaquin County for a permit to construct and/or install tM wort described. this application is <br /> wade in compliance with son Joaquin County Devetopment Title, Chapter 9-1115.3 and the Standards of fan Joaquin County"tic Neatth <br /> Services. Ertvtronmental Neatth Division. M <br /> Job Address/or APM 350* GC)QON1 ao Avg- city Lj1GkToN Parcel flte/A►MMT <br /> Owner's Nave!S�%OT G-)AAoI,.KM�fy-Address 901 evil- 104msr, 1CM33&QN,A0 Ph«u O IG <br /> Contractor HtmeL e.)J11iyIJ' Ct4TA1` AddressAklfrLkW$i0C RV.K�QLICN Phar ice)-4-910 <br /> i <br /> Sub Contractor S(jL- i�rl ! V- be(t0WbAddreu28Cb AYILnE SMt;04- llcOCO-12 IL Phar 910-61%Z <br /> f_ TYPE Of YELL KRIP: 0 NEW WELL 0 REPLACEMENT WELL 0 MONITORING WELL / O OTHER <br /> 1 E) DESTRLKT1Ol 0 OLiT-OF-SERVICE WELL 0 GEOPNTSICAL WELL B it SOiL 11MING S90411roS <br /> t{ 0 INSTALLATION 0 WELL VME14 REPAIR 0 CROSS-CONKCT REPAIR 0 VAPOR EXTRACiION JELL ! <br /> Q New p Repair N.P. DEPTN KRf SET FT. FIRST WATER LEVEL <br /> (TYPE OF KM) <br /> INTENDED USE TWEE OF WELL ;INSTRUCTION SPEL'MICATIONS <br /> U INDUSTRIAL 0 OPEN BOTTOM DIA- Of WELL EXCAVATION DIA. Of CONDUCTOR CASING <br /> — <br /> ll DowstIC/pNIVATE U GRAVEL ►AWSiZE TYPE OF CASING/STEEL/PVC DiA.OF WELL CASING <br /> r U PUBLIC/KMiC(PAL 0 DRIVEN BfPTN OF GROUT SEAL SPECIFICATION <br /> U IRRIGATION/AG U OTHER GROUT SEAL INSTALLED BY GROUT BRAID NAME <br /> U MONITORING OR= SEAL rtmmt 0 Yes 0 No CONCRETE PEDESTAL BY DRiLL.ER: 0 Yes p No <br /> APPROX.OE►TM LOCKING CHESTER BO(/STOVE PIPE <br /> PROPOSED CONITRUCTIONiDAILUNO METHOD: MUD ROTANT_Alt ROTANY_AUGER_WALE_OTHER_ <br /> ti I hereby certify that 1 have prepared thfs application and that the work will be dor In occordence with San Joaquin County Ordinances, <br /> State Law, and Rules and Regulations of the San Joaquin Canty. Home owner or licensed agent's signs ur*c*r ifl�sthe Sfo�owing: Of <br /> certify that In the performance of the work for which this permit is Issued, i shot( not employ persons <br /> Lew of Californis.e Contractor's hiring or tub-contracting signature certifies the fellowingt e I certify that in the performance <br /> of the work for which this Permlt is issued, I shalt employ person subject to YORKMAN'S COMPENSATION Law of California.* THE APPLICANT <br /> MUST CALL 24 NOURS IN ADVANCE FOR ALL REGUIRED RSPKIVIB AT ROS)488-2122. Complete drawing at lower area provided. <br /> Signed y- Title Rt"b- ft'r D.te9-t��e <br /> - PLOT PLAN (Draw to Scale) Scat.--j-- <br /> 1. <br /> caleI •1. Naeem of streets or roods nearest to or bo"Ing the property. A. Location of house sewage disposal system or <br /> 2. Outline of the property, giving dimension and North direction. proposed expansion of sewage disposal systems. <br /> 3. Dimensioned outlines and location of oil existing and proposed S. Location of welts within radius of ISO ft. on <br /> structures, including covered areas such as patios, driveways, the property or adjoining property. <br /> ` and walks. - — - - <br /> 3619 <br /> r RIEDEL ENVIRONMENTAL SERVICES, INC. <br /> PH.510-222.7010 _ - - <br /> Il 11-N <br /> 4130 LAXESIDE OR. <br /> RICHMOND.CA 94M 12ace1 <br /> V7, ig <br /> PAY _ __-_—_—� $v 1 <br /> TO THE <br /> ORDER OF_ <br /> DOLLARS <br /> 0.CEWwTO PUSA OrnCE <br /> WELLS FARGO BANK <br /> ee00 SAM FARO AVEMIE 0.CfHWTO.G 61]e �- <br /> 1 <br /> FOR <br /> i <br /> 1400 36 L 91' 1: L 2 1000 21,81:0 L 3 L 01S5881' <br /> DEPARTMENT USE ONLT <br /> • Date �} Ano <br /> Application Accepted By <br /> Grout inspection ty <br /> Date Pump Inspection BYDate <br /> Destruction inspection By Data Comments: <br /> ACCOUWTM ONLY: AIDE <br /> FACE �� �� • <br /> PE CICES, FEE we AMOUNT REMITTED SN EO IT DAZE ►ERNNTIBEfYICE REDDEST NUMtEt NIVONaT <br /> l . °� ,Z <br />