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Addr,s, 39201 Fremont Blvd, Fremont, CA 94538 <br />Sub Contractor n/a <br />ROTARY AUGER X OTHER CABLE AIR ROTARY METHOD: HUD PROPOSED CONSTRUCTIOWDRILLING <br />v V V V <br />AFFLIGAIIUM 1-1111 Wt1././rutur <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P 0 BOX 388, 445 N. SAN JOAOUIN ST, STOCKTON, CA 96201-388 <br />(209) 458-3420 <br />tO3 <br />945,24A/ pfri <br />Application is here by made to the San Joaquin GwIty for a permit to construct and/or instatl the work described. This appli2it.rkr1 is <br />made in comPliance with San Joaquin County Development Titte, Chapter 9-1115.3 and the Standards of San Joaquin County Public We6lth <br />Services, Enviramgentat Health Division. <br />Job Address/or APNX 5400 Pacific Av City Stockton Parcel Size/APN4 /192 -;0110 <br />NON.REFIDIDAEILE PERMIT_ EXPIRES 1 YEAR FROM DATE ISSUED <br />Complete in Triplicatn1 <br />Contractor V & W Drilling <br />TYpg OF WELL/PumPi ES NEW WELL <br />0 DESTRUCTION <br />a INSTALLATION <br />U New 0 Repair <br />(TYPE OF PUMP) <br />C] REPLACEMENT WELL MONITORING WELL <br />cuT-OF-SERVICE WELL GEOPHYSICAL WELL * <br />WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR <br />N.P. DEPTH PUMP SET <br />0 OTHER <br />0 SOIL BORING <br />0 VAPOR EXTRACTION WELL 4 <br />FT. FIRST WATER LEVEL <br />CI INDUSTRIAL 0 OPEN BOTTOM CIA. OF JELL EXCAVATION 11" <br />DOKESTIC/PRIVATE SO GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC PVC Sch 40 <br />DEPTH OF GRCUT SEAL AOOTOX 48' C PUBLIC/MUNICIPAL 0 DRIVEN <br />IRRIGATION/AG 0 OTHER GRCUT SEAL INSTALLED BY \./(St VV Drilling <br />13 MONITORING GRCUT SEAL PUMPED: Ct Yes 0 No <br />APPROX. DEPTH 70' LOCKING CHESTER BoX/STOVE PIPE <br />I nereby certify that I have prepared this admication and that the work will be done in accordance with San Joaquin County Ordinances, r‘ <br />State Laws, and Rules and Regulations of the Si Joaquin County. Home owner or licensed agent's signature certifies the following: "! <br />certify that in the performance of the work for u4ich this permit is issued, I shall not employ persons subject:to WORKMAN'S CCMPENSATION <br />Laws of california." Contractor's hiring or s:jo-contracting signature certifies the following: " I certify that in the performance' <br />of the wcrk for which this permit is issued, I employ persons subject to `.:CRKMAN'S COmPENSATION Laws of California." THE APPIICANI <br />MUST CA11,24 HOURS IN ADVANCE FteR,IX LURED IISPECTIONS AT (20914N-3423. Complete drawing at tower area provided. <br />Steven A. Bright Tit le President <br />Application Accepted By <br />Grout Inspection Bytidl'1,-'-q Date/)-II(- Pumo Inspectioni Date <br />n p Destruction Inspection Sy Date Cammts: ot _4_0/ f <br />P GROUT BRAND NAME Portland Type II <br />CONCRETE PEDESTAL BY DRILLER: 0 Ye$ CI No <br />Christy Box <br />Signed X <br />\ \- <br />Date Area <br />ACCOUNTING ONLY: AID4 <br />PE CODES FEE INFO AMOUNT REMITTED 1 CREW:CASH RECUYED BY <br />11/9,03_ . 3O I A44/ <br />1/z ,tv9c frvidiAb 5(:‘ <br />INVOICE DATE PERMITISERVICE REQUEST NUMBER <br />ii/7,15/z7( <br />DEPARTMENT USE ONLY <br />Date 1/10/1995 <br />Phone # 510/794-2277 Owner's Nam Montgomery Ward & Co, Inc e <br />Address Lic4 Phone # <br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br />Lica 658786 phwe 0 916/631-7165 <br />DIA. OF CONDUCTOR CASING n/a <br />DIA. OF WELL CASING 4" ID <br />SPECIFICATION PVC Sch 40 <br /> Ii <br />I FAC* <br />Address P.O. Box 51, Rio Vista CA