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ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOY '46, 446 N. SAN JOAQUIN ST. STOCKTON. CA 9`11.388 <br /> '"We loos► 486.3420 PAYMENT <br /> NON•REFUNDADtE PERMIT EXPIRES i YEAR FROM DATE ISSUED ,RECEIVED <br /> !Complete In Tripp"") I F£8 Z 8 t5-,�S <br /> application is here by made to the San Joaquin County for a permit to construct and/or install the work ' rf�lect.ljhjps( NITOtion is <br /> made in compliance with San Joaquin County Development Title, Chapter 9.1115.3 and the Standards of }i1$ �ateh <br /> services, Environmental Health Division. ENVIR MENTAL HEALTH DIVISION <br /> yob Address/or APN# FbK f �oAD # $ City �-0C1C1b N Parcel size/APUN <br /> ,wner's Mame+ CAfLmI[L e �h1 G Address 232( W•�a 431410061104 SC � .5 �.D Phone� - i C-4 <br /> :ontractora7(� � ��C QWC, Address+9E1 �A 10P?(A`� PO E Lim ~P� I Z54��# cn 10 <br /> ,ub Contractor N /A Address Lie# i Phone # <br /> 9'33-140 <br /> MOO <br /> "YPE OF YELL/PUMP: [) NEW WELL EI REPLACEMENT WELL EI MONITORING WELL # O OTHER A"Cw� <br /> 11 DESTRUCTION 11 OUT-OF-SERVICE WELL D GEOPHYSICAL WELL * IL BORING Au <br /> Q INSTALLATION [) WELL SYSTEM REPAIR D CROSS-CONNECT REPAIR [I VAPOR EXTRACTION WELL # <br /> p New 17 Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL (Z fiEET <br /> TYPE 0 PUMP) 17MATi-D)— <br /> YTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ) INDUSTRIAL I) OPEN BOTTOM DIA. OF WELL EXCAVATION 3`10404 DIA. OF CONDO TOR CASING A <br /> ) DOMESTIC/PRIVATE D GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC-14 DIA. OF WELL LASING N 1A <br /> :) PUBLIC/MUNICIPAL [I DRIVEN DEPTH Of GROUT SEAL 10 FiREI— SPECIFICATIONS N IA W <br /> A IRRIGATION/AG [) OTHER GROUT SEAL INSTALLED BYSICM--PAC GROUT BRAND NV"zf>"-q 6i Ih <br /> :) MONITORING rr GROUT SEAL PUMPED: D Yes AND �ACONCRETE PEDE TAL BY DRILLER: D Yes XNo <br /> .PPROX.DEPTH 1 d � LOCKING CHESTER BOX/STOVE PIPE <br /> ROPOSED CONSTRUCTIONIDRILLING METHOD: MIA ROTARY._ AIR ROTARY_XAUGER,,,_ CABLE OTHERw_ � ^'� 1x~` <br /> hereby certify that I have prepared this application and that the work will be done in accordance with Sin Joaquin County Ordinances, <br /> Late Laws, end Rules and Regulations of the San Joaquin County. Now owner or licensed agent's signatur4 certifies the following: "I <br /> ertify that in the performance of the work for which this permit is issued, I shall not employ persons subject to 41ORKRAN'S COMPENSATION <br /> aws of California.■ Contractor's hiring or sub-contracting signature certifies the following: " 1 cer ify that in the performance <br /> i the work for which this permit is issued, i shall employ persons subject to WORKMAN'S COMPENSATION Laws df California." THE APPLICANT <br /> ,UST CALL 24 HOURS IN ADVANCE FOR ALL REDUIRED INSPECTIONS AT(2011)4W3423. Complete drawing at Lower area p ovided. <br /> .igned X sa 2 (JVMr Title W [5 T Date, <br /> PLOT PLAN (Draw to Scale) Scale " to &IS3 <br /> i <br /> DEPARTMENT USE ONLY <br /> t,"pLication Accepted By Date ZQ12(f Area <br /> grout inspection By Date Pump Inspection B,�y Date <br /> Destruction inspection By Date Comments: Ian-6u1 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE PERMITISERYICE REOU T NUMBER INVOICE <br /> ?�1 �f3 1fi y8 '"D K <br /> I <br /> EO*cl L6=6916T 01 WONT WUZO:TT b66T-9Z-LO <br />