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ICOM NtFUMjIABt�ft11MIT EXVIII�Y 1.Y.th R•MUaf p.r;t reaua.N
<br /> AaDitcaCion n here by made to the San Joaquln Cnu,tY to- r perm+t t:, .- ,lr.r-+ 'rid/or 11,,IAIl the work descrtbod. Ihtl. app:tcAtt4n is
<br /> node in corpl,ance w',th Sen Joaquin Canty Develosowrt I,tte• (t,.ute . S`15 ' ;..Lf the'Stn,dards of Son .,uactu,n CoWrty P'Ablta' Neatth
<br /> Envirnrrsental Health Utylsinn.
<br /> I t 1 1
<br /> Joh AtlAr err/ur AVNI_ _ _) Y ��_ _ Vgrarl Sl to/APNM__,
<br /> 7 i --- _ C t _.c.L�- - -
<br /> owner,s beer.Lu�l= t, At, Ablr• ---t-I-� --- ---�'--' '-_�.---- vhury a
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<br /> Cunt rac t or I ', f/ i 1. , !l,• Addre%sj_, _,_�'._ -'_.�_..__�+1 ice - i_ Phone a-I 1
<br /> SuD Contractor Address chose ■
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<br /> !YLL Ot VELI/M1Mo;, NEW WELL (1 REPLACEMENT WELL II MOkt 100 I MG,Wt,L I B_,_.
<br /> ,I DESTRUCTION (1 rAJT•OF•SERVIr.E Wkll 1) GEOPHYSICAL ALL M___•,__ fi SOIL BORING
<br /> (1 INSTALLATION (I WELL SYSTEM RIFAIR 11 CROSS CONNECT RFPAIR I7 VAPOR EAIRACII)M VELI #____ii• _ (1 mew (1 Repair N•P• _-____ OfP/M V1RIP Sf.f ri, FIRST GAYER :E JEI,_.
<br /> :TYPE OF PUPIP)
<br /> IRI fW.P o USE iYPLQQ V%k QOIEfT"U 1-19M A Litt ylfl;,!.fl -V;
<br /> I1 INWUSIRIAL >( OP ' BOTTOM DIA. OF WELL EXCAVATION i 4.' DIA. Of CON000TOR CASING _-^
<br /> TIPE 01 CASING%% E:.L/PVC•' DIA. Or WELL CASING
<br /> �C'JMESTIC/PRIVATE (] GRAVEL PACK/SIT' '
<br /> _ __...iL:.L....L...__.- -
<br /> (1 POALIC/MUMTCIPAL I) DRIVEN DEPTH OF GROUI SLA -.I L, -' -,_ SPECiFICA'IOM'i '-k
<br /> (] TRRiG1T70N/AG (1 r•,-.[R GROJT SEAL INSIALLI'D BT y,�,;,'. .GROUT BRAND
<br /> s• MONITORINGGROUT SEAL PUMPS!': Y•»s ,7 Mo CGNCRETE PEDESTAL BY DRILLER: 0 yes I1 Mo
<br /> APPROX.DEPTH M1I LOCKING CHESTER BOM/STOVE PIPE -----
<br /> PROPOSf_0 CfIRSTAUCTIONIORILUNO MITH00: MLA ROTARY__ AIR ROTARY— AUGER— CABLE__ OTHER____
<br /> 1 heresy certify N.at i have prepared this apptv,,rst+r ,nd that the work will be done in accordance r+th San Joaquin Canty Orairotaer,
<br /> State Lon, and Runes and Regulations of the San Jugquin County. Nota owner or licensed agent's signature certifies the foltowirsr,: -i
<br /> certify that in the perfortsarxe of the work tot ,Mich this permit iN issued, 1 shall not eelptoy persons subject to WORKMAN'S COMPEMSATION
<br /> Loof California." Contractor's hiring or subcontracting signature certifies the following: " 1 certify that ,n the performance
<br /> of the work for which this psrmlt is issued, I %hail owtoy persons MA
<br /> subject to WORKM'S COMPENSATION Laws of California.' THt APPLICANT
<br /> MUST CALL 24 HOURS IN ADVANCt FOR ALL REOUTAED INSPECTIONS AT(209)"11421. Ccmplete drawing at lower area provie d.
<br /> Signed )t _�c Tr / -_ not
<br /> PLOT PLAN (Draw to Scale) SCALP—_ to-
<br /> t, NaeeA of otreets or roads nearest to or banding the property. 4, tocation of house swage disposal systzw .r
<br /> outtins of the property, giving dimensions and North direction. proposed espans+tln of savage disposal sV.t%ax.
<br /> s. Dimensioned outlines anid location of ell e.iilting and proposed S. tocat'cx, n( vett% within r*dlun of TSO fr.. .,n
<br /> structures, including Covered areas such No paCios, dr%vewavt., the property or adjoining pr.,7.4rty,
<br /> ane walks.
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<br /> 1 i rf! A iG 1 19 5
<br /> iFl! .n aew���.r+Ir�2ees��SIN wii..e ��1�1�lAr�..�Ml
<br /> DEPARTMENT USt ONLY 67
<br /> Appi%cat on ALcepted 9Y 11 t�Sr ' Da� [� 'r2., ) .. Arae, j
<br /> Gr.A,t Inaiecttor, BY Data_,.!_.u. .._•l'C_ PungInsWct,nn B wy�IC`� D -
<br /> L, .trtAAlc,n !r,►p►ctign RY_ �,�__.._,r_.....�.. Dots _ Caiq,eritst •;�� __...Y=_' `..._.__-_�,__ ` _�
<br /> ACCOUNTINo 0111 Y: AION 1Afp
<br /> eI CDOtit Ftt lafo i AMOUNT UNITTFD fjHiCR ABM REctlyt0 BY OATSi PERTaTISERVICE 111QUtS1 NUlF9E0 YNttlh E jtt
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