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SAN JDAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> NVIRONMENTAL HEALTH DIVISION — <br />' P 0 BOX 388, 445 N SAN JOAIIUIN ST, STOCKTON, CA 95201 388 -- <br /> (2091 468 3420 <br /> NDN REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> (complete aINFiM) <br /> Ca-10n is nere by made to the 6San Joaquin County for a permit to construct and/or instatt the work described This appl cation s <br /> r co=t lance with San Joaquin County Develzpment Titte, Chapter 9-1115 3 and the Standards of San Joaquin Co+rity PtMLic neal-- <br />'errsces, £'1111ortnentaL Neatth Division�c 1 I-. G <br /> cc Aocress/ar APW# ..c � Qdl,s/ flGju,W�r�liflP City cSY4e1CP-f1N Parcel Size/APWtt <br /> Address—N;:1,$— Ujksr/7f� -Cl 67+ C'I eS4 Phone - 070T' 6 03 .Z y <br /> l/f' <br /> p <br />'cr--ac-vr�Ohr�Q�J�i/r%Y�y�JH�...7���^�Addresss�fl rJO�cf�..�/] r LIe# Phone A/lk' 7ZJGG <br /> c Con-ractor/4,7-.4/100'.,/z V."Zod AddressAd.rCThI /G6-4,; LIc#(a Is?(0/ T Phone : z <br /> flE OF VELLdUMp X NEW WELL ❑ PLACEMENT WELL � 110NITDRfNG WELL # L+ E) OTHER <br /> [] DESTRUCTION Q CUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL # X SOIL BORING <br /> [] INSTALLATION 11 WE-L SYSTEM REPAIR E7 CROSS-CUNNECT REPAIR (] VAPOR EXTRACTiOk VILL <br /> ❑ New ❑ Repair H P DEPTH PW SET FT FIRST WATER LEVELS 7?D � <br /> M-,P--- OF Pump) <br /> 7rNDEO USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> p <br /> kDl;STRIAL [] OPEN BOTTOM DIA. OF WELL EXCAVATION p !�. ��� DIA OF £ONDUCTQR CASING <br /> CCNESTIC/PRIVATE [3 GRAVEL PACX/SIZE T"PE OF CASIWG/STEEL/AVL DIA OF WELL CASING <br />' �L)8L'C/AUNICIPAL C] ORIVEW DEPTH OF GROUT SEAI.7 �, e1�Tr�.+,.U,,-eSPECIFICATION (S Yae/�C <br /> KR'GATIOW/AG [] OTHER GROUT SEAL INSTALLED BY .4j^/ <<t0- GRCUT BRAND HANE =Q 4 <br /> - <br /> J� *C41TC)RlkG GROUT SEAL PUMPED ff Yes ❑ No CONCRETE PEDESTAL BY DR=L_FR Yes V'Lc <br />�FFROX DEPTH 70 �Q LOCKING CHESTER BOX/STOVE PIPE i(/L2 <br /> ROPOSED CONSTRUCTIONIORILLING METHOD MUD ROTARY AIR ROTARY— AUGER4 CABLEOTHER <br /> teeny certiTy that I have prepared this appL.cation and that the work wiLl be done in accordance with San Joaquin County Ordinances <br /> Le <br /> Laws, and RuLes and Regu{ations of the San Joaquin County. Hage owner or licensed agent's signature certifies me •ollowsng <br /> er- -y -hat in the performance of the work for wnich this permit is issued, I shaLL not employ persons subject to WORKMAN'S C" PENSATIOi <br /> avS OT California 11 Contractor's hiring or sLb-contracting signature certifies the foLLowing " I certify that sr the perrormance <br /> -e Torr o- which this permit is issued, I s.alL eirptoy persons subject to WDRY,MAN'S COMPENSATION Laws of Califorr a Ti♦.APPUC-X- <br /> UST CALL 24 H URS IN ADVANCE FOR ALL REQUIRED IIISFECTIONS AT (2081 488 3423 Complete drawing at lower area provided p <br /> 3 Snec /i'/ Tit[eyC,-,'%yfif�?_&' <br /> I I I <br /> I I I <br /> I J I I I <br /> DEPARTMENT USE ONLY <br /> tolication Accepted By = Date ��� � Area <br /> lrout Inspection By Date Pump Inspection By n Date <br /> es-ruc-ion Inspection By Date <br /> ACCOUNTING ONLY AID# FACS <br /> PE CODES FEE INFO AMOUNT REMITTED CHECXIiCASH RECEIVED BY HATE PERUMSERVICE REOUEST NUMBER I INVOICE <br /> E <br /> o I 7-9sT4 # 7s I �� <br />