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aAPPLICATION FOR INELLIPUNIP PERMIT <br /> SAN JOAQUIN COUNTrBLIC HEALTH SERVICO <br /> L HI <br /> ENVIRONMENT L HEAL <br /> P 0 BOX 388, 445 N. SAN JOAauIN Sp-R&Y"j <br /> ,f <br /> PUBUCT113 <br /> ..AT.I-Zl SERVICXS <br /> 199 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM U"IAL PERMIT <br /> (Comp k"Triprmte) <br /> Application Is here by made to the San Joaquin County for a permit to construct and/or install the work described. This application is L <br /> made in compliance with San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br /> Services, Environmental Health Division. <br /> Job Address/or APNN F Landi(1/ 22W 'M F4A (X 1W <br /> C&f- Wow <br /> Mki da CLL� 4 Rd— city SWCIS42ylk Parcel Size/APN# <br /> Owner's Name Ciiv & sLockton, DPW Address 'Ug' W lAdor-n445-toc.ki:on, CA 9529IL-1t Phone #209-Wl-8322- <br /> too fpr-; f ite, Avq� ' 3.00 <br /> Contractor C4L%rnJ?, Dmss-4yr I McjKev, tnc, Address lahjaLdn Creek� CA LIc# Phone 0510-3-3A-ze0o <br /> PO 15a*K <br /> Sub Contractor V*I;tern GI`rA+4eKFI0r&- fi6n Address­*A. .. a L I c#C29 00312-14Phone #916­31-3-019 <br /> WO" <br /> TYPE OF WELL/PUMP: [I NEW WELL El REPLACEM5T1GR NON I TOR I NG # W--G.A EI OTHER <br /> EI DESTRUCTION El OUTr.Vr,1E'RVICf*'4 ?"13 GEOPHYSICAL WELL # El SOIL BORING <br /> DeeA iadwd EI INSTALLATION [>¢ STim, El CROSS-CONNECT REPAIR [I VAPOR EXTRACTION WELL # <br /> Slckdafr PLkrnP EI New [I RePv yDEPTH PUMP SET 3 q FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) 4c� <br /> INTEN CONSTRUCTION SPECIFICATIONS <br /> (I INDUSTRIAL [I OPEN 8 DIA. OF WELL EXCAVATION 10-41CA3 DIA. OF CONDUCTOR CASING-OMP, <br /> (I DOMESTIC/PRIVATE 14 GRAVEL PACK/SIZE±7-/l re TYPE OF CASING/STEEL/PVC PVC---r-ktL10 DIA. OF WELL CASING 4-Lnch <br /> (I PUBLIC/MUNICIPAL 13 DRIVEN DEPTH OF GROUT SEAL 10--I5 fSa SPECIFICATION_!jj.j2�' <br /> [I IRRIGATION/AG % I OTHER GROUT SEAL INSTALLED 0 drille-r GROUT BRAND NAME <br /> X MONITORING GROUT SEAL PUMPED: ;4 Yes El No -fMft1('eCONCRETE PEDESTAL BY DRILLER: 0 Yes D No <br /> APPROX.DEPTH 40 LOCKING CHESTER BOX/STOVE PIPE--­a Vi CQM12 m vy4k (ockirl rtp NA <br /> PROPOSED CONSTRUCTIONJORILLING METHOD: MW ROTARY AIR ROTARY_ AUGER_K_ CABLE_ OTHER_ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, <br /> State Laws, and Rules and Regulations of the San Joaquin County. Home owner or licensed agent's signature certifies the following: "I <br /> certify that in the performance of the work for which this permit is Issued, I shalt not employ persons subject to WORKMAN'S COMPENSATION <br /> Laws of California." Contractor's hiring or sub-contracting signature certifies the following: 11 1 certify that in the performance <br /> of the work for which this permft is issued, I shalt employ persons subject to WORKMAN'S COMPENSATION Laws of California.,, THE APPLICANT <br /> MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT(200)488-3423. Complete drawing at/�LLower area provided. <br /> Signed X Title ta�t,�/ Date <br /> PLOT PLAN (Draw to Scale) Scale- to <br /> 1. Names of streets or roads nearest to or bounding the property. 4. Location of house sewage disposal system or <br /> --2—out-Line-Qf_th,e-p-�operty,. giving dimensions and North direction. proposed expansion of sewage disposal systems. <br /> sed 5. Location of welts within radius of 150 ft. on <br /> thp orooerty or adjoining property. <br /> -J <br /> PAY N' <br /> Det pLkE7 r.1 r r`I.F.-11.1 IF )7 <br /> JAN 2 19(-- <br /> 6 MW-6A <br /> SAN J0A0LJ1(,,, VICES <br /> PIA31-IC HEAL i LI Jr I DIVISION! <br /> R <br /> Application Accepted By NVIRONMeNTAI, HFAL, 7 F__ Area <br /> Grout Inspection By Date Pump Inspection By Date <br /> Destruction Inspection By Date Comments: J'fAfJ6JyJ#1 L416'OkfAft ftAdr1*40 e <br /> 41c.e g144, eo-<1,'1,-,,y CF- ,Fe-,,.,rh <br /> ACCOUNTING ONLY: AID# FAC# 1 s"ki <br /> PE CODES FEEINFO AMOUNT REMITTED CASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br />