Laserfiche WebLink
_ .�... %pPLICAT(UK FOBwEWPUlY1P PERMIT <br />` S ;JOAQUIN CdUNTY PUBLIC HEALTH SE9Y1C>GS: <br /> ENVIRONMENTAL HEALTH DIVISION <br /> PO BOX 388. 448 AL SAS JOAdUIN ST, STOCKTON. CA 86201-388 <br /> (2091,488.3420 <br /> NON.A FUNDABLE PER1flT EXPIRES I YEAR FROM DATE 14SUED <br /> icm is <br /> Application ti here by otiede to the 5are my Dn t+tri tnr a Title, Chapter 9-11 5ermit to e3 and/or.instat.t the mQek described. This the standards of San JoaVin County PubtictHealth <br /> ,Wade in ear�liance with San Joaquin County OevelCpteen r P <br /> Services, Environmental Health Division. <br /> - City Parcel Size/PPHN <br /> job Address/or APNM <br /> Owner's Name 6 I y 6— &, 1 __ Address '/'3`36 A • a �"-'/ �Z��W-� Phone It `�bb'70 <br /> 10 O <br /> (� ✓-L L Addrtsa Ua/Z,— Lia* 2 9O Phone t 707-37F`�/.- <br /> Contractor. ��//�� ?may <br /> Address �Z ' lFdtk `?-�—`�'icN Phone +p <br /> Stab Contractor `J <br /> TY OF P: fid.N9W YELL Cj Re-LICENENT DELL MONITORING WELL # -3 C] OTHER <br /> /C] DESTRUCTION (I OUT-OF-SERVICE WELL GEOPHYSICAL WELL S SOIL BORING . <br /> C3 INSTALLATION (I %al. SYSTEM REPAIR CI CROSS-CONNECT REPAIR E3 VAPOR EXTRACTION WELL S - <br /> C3 Now 13 Repair N-P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> i�TaDFO U WE CDNSTRUCTI4N SPEpFICATIONO <br /> C3 IIWUSTRIAL C3 OPEN BOTTOM CIA. OF WELL EXCAVATION OIA. OF CONDUCTOR CASING- <br /> (I <br /> ASING _CI QOMESTIC/Pil[VATE ) GRAVEL PACK/9IZE�3 TYPE OF CASING/STEEL/ C DIA. OF WELL CASING air �Q <br /> PUBLIC/1'RIMICIPAL LI DRIVEN DEPTH OF GROW SEAL �idf 't P e SPECIFICATION <br /> El GROUT SEAL INSTALLED BY VI&M''"�y GROUT BRAND NAME <br /> C] IRRIGATION/AG 1:3 OTHER S <br /> HONITOItING GROUT SEAL PUMPED: jYes p No CONCRETE PEDESTAL BY DRILLER: q Yes No <br /> APPROX.DEPTN - 40 <br /> LOCXING CHESTER BOX((/STOVE PIPE <br /> PROPOSED CONSTRUCTIGiUDRILLING METHOD: MW ROTARY AIR ROTARY_,_,_ AUGER CABLE_ OTHERS-- <br /> I hereby eertify that I hew prepared this application and that the work will be done In accordance with San Joaquin County ordinances, <br /> State Laws, and Rutes and Regulstiona of the ser+ Joaquin Courcy. Hass owner or Licensed atoy persa ubalectt to-WORKKpH S COMPENSATION <br /> certifycertify that in the perfarmenee of the work for 1-hich this permit n issued. [ shed not'employ pe <br /> Laws of California." Contractor's hiring or sub-contrectin8 signature certifies theAN'tCllowinAT " 1 certify that is the performance <br /> ICANT <br /> of the work for which this permit is issued, I aall employ persons subject to WOR KHANrS COMPENSATION Laws of CaElfarnia.° THE APPLICANT <br /> MUST CALL Z Ho IN ADVANCE N ALL REQUIRED L"PECT1008 AT 12001439-3423. Complete drawing at tower'airea provided. ars � it <br /> Title ?./tiw Date <br /> Signed X <br /> 9n <br /> DEPARTMENT USI:ONLY <br /> Date Area <br /> Application Accepted By <br /> Grout Inspection 8y Out <br /> 2.. pump Inspection By Date <br /> Destruction Inspection BY <br /> Date. Comments: <br /> ACCOUNTING ONLY: AIDS FACS <br /> Pt cents FEE WFU AMOUNT REUMTED cHKXJICASH RECEIVED By DATE PERMITrSFNY1Ci: REQUEST NUMBER INVOICE <br /> I <br />