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iAPPLIGAIIUN tUN WtWrvmr rcnm" isC- SAN IGAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH IlIVISION L��!/fRr ,I A <br /> P 0 80X 338, A46 N.SAN a�10�8.3b203TOCf(TON, CA 96207.388 PFq Ts���Cfiy`71, <br /> N0W;EFU9OAet PERMrt EtlPIRES 1 YEAR FROM DATE ISSU@ 95 Jq y 3 J E <br /> tCawpMn ie Trol'oON P� Qr/ is <br /> Application is here by made to the San Joa¢in Carty for a permit to constnact and/or install the work described. This aLWQlif <br /> made in caapilance ufU San Josquin County Devei�ent Ti Ste, chapter 9-1115.3 and the Standards of San Joowin County P�bUc ,�polth <br /> Services, Elrviroraaental Health Division- <br /> 5400 Pacific AV city Stockton _ Parcel Si telAPN2�� <br /> Job Address/or APNs 510/794-2277 <br /> Montgomery Ward&Co, Inc. ,�r� 39201 Fremont Blvd, Fremont, CA 94538 Phone M <br /> Cwro is wax 658786 phyte 2 916/631-7165 <br /> Contractor <br /> V&W Drilling Address P.O. Box 51, Rio Vista CA Lic2 <br /> SWb contractor n/a <br /> Address Lic2 Phone >Y <br /> TYPE OF YELL/PUMP: Qj NEW WELL ❑ REaLACEMENT WELL it MONITORING WELL 23,4,5&6 ❑ OTHER <br /> OF-SERVICE WELL I] GEOPHYSICAL WELL a -tl SOIL BORING <br /> ❑ DESTRUCTION ❑ OUT- VAPOR EXTRACTION WELL <br /> ja INSTALLATION ❑ l✓;1L SYSTEM REPAIR p CROSS-CCNMECT REPAIR FY. FIRST WATER LEVEL <br /> — <br /> a❑ NeN ❑ Repair N.P. DEPTH PIaP SET <br /> (TTPE OF PUIW) `w <br /> INYENOED MED TYPE OF YVELL CONSTRUCTION SPKMCATIBNS n/a <br /> ❑ INDUSTRIAL ❑ WEN BOTTOM DG. OF WELL EXCAVATION 11" DIA. OF CONDUCTOR CASING 0 <br /> ❑ DOMESTIC/PRIVATE a GRAVEL TTCM [7E�� TYPE OF CASING/STEEL/PVC PVC Sch 40 DIA. OF WELL CASING 4" ID�— f"1 <br /> SPECIFICATION PVC Sch 40 V <br /> (I PUBLIC/MUNICIPAL ❑ DRIVEN DEPTH OF L INSOUT SEAL AooV&rox 48' Portland Type II <br /> GROUT SEAL INSTALLED BY V&W Drilling GROUT BRAND NAME <br /> (I IRRIGATION/AG ❑ OTHER Yes ❑ Ae CONCRETE PEDESTAL BY DRILLER: ❑ Tea ❑ NO <br /> q MONITORING GROUT SEAL PIMPED: 2 <br /> 70 Christy BOX <br /> __ LOCKING CHESTER BOX/STOVE PIPE <br /> APPROX.DEPTH <br /> PROPOSED CDNSTRUCTIGKMFA MG METHOD: MIA ROTARY_ AIR ROTARY_ AUCw:R X CABLE` OTHER_ �L' <br /> [ Mentor certify that I have Prepared this apgt—7- and that the work viIi be done in accordance with San Joaquin Counry Ordinances, <br /> State Laos, I shall rat eroloy persons SWbiept:to WORKMAN'S CCNP°-lSAT10M <br /> and Rules and Regulations of the San Joaquin County. Home owner or licensed agent's signature certifies the following: <br /> certify that in the perforamnce of the work for vhich this Par""t is issued, • t certify fMet in :he perforaance <br /> Laws of california." ContracTor's hiring or s.b tracting signature certifies the fCAN' OMPENSB: Of <br /> of the :crk for which this permit is issuedd,, I�tL eopt AT per o�ns su 3jec tO:�e��Lete drawi ng at Lower Pcoy i ded enol a." THE APPLICANT _h <br /> MUST CAU 2A NOUA6 IN ADVANCE FBM- _ Date 1/10/1995 <br /> Steven A. Bright Title President <br /> signed X <br /> I <br /> OEPARTHUBIT USE ONLY <br /> Date Arees—f <br /> Application Accepted BY Date <br /> Datd "'mP Inspection 33 <br /> Grout inspection 3Y e6 svL,Ti <br /> Oes[nc:ion Inspection BY <br /> Date CaPments• A� r ,T _ <br /> ACCOUNTING ONLY: <br /> 0.ID2 FAC% <br /> INVOICE <br /> PE CODES FEE 100 AMOUNT HEMMED I dA'q(i1CASH RECEIVED BY Oi� P6IWTISERVIC�EDU�NUMBFit I I� <br /> //z-�'? s -mow ami✓0, S/u}� j�4 p� <br />