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TYPE OF WELL/PUN : (1 NEW WELL 1) REPLACEMENT WELL )(:,NONITORINS WELL # (0 (1 OTHER -DESTRUCTION II OUT -Or -SERVICE WELL (3 GEOPHYSICAL WELL 0 El SOIL )e BORING 11 INSTALLATION I) WELL SYSTEM REPAIR (1 CROSS-CONNECT REPAIR [1 VAPOR EXTRACTION WELL 0 I1 New (1 Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL (TYPE OF PUMP) INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS II INDUSTRIAL (1 OPEN some DIA. OF WELL EXCAVATION g--1/1/G", DIA. OF CONDU TOR CASING ET DOMESTIC/PRIVATE V:GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC /;21/e, DIA. OF WELL ASINO (3 PUBLIC/MUNICIPAL 0 DRIVEN DEPTH OF GROUT SEAL a -/,9,--L--).-..- SPECIFICATION El IRRIGATION/AG (1 OTHER GROUT SEAL INSTALLED BY ,g. i; fP/k7/1Z//1/40UT BRAND N )4:NCWITORING GROUT SEAL PUMPED: () Yes I1 No CONCRETE PEDE APPROX. DEPTH '2- (-I 15C-='-f- LOCKING CHESTER ROT/STOVE PIPE TAL BY DRILLERI (1 Yes TI No PRDPOAFD CONSTRUCTIONIBRILLINO "WHOM MUO ROTARY AIR ROTARY_ AUDIR"X CABLE _ OIHIR_ _ I hereby certify that I have prepared this application and that the work will be done in accordance with Sin State Laws, end Rules and Regulations of the San Joaquin county. Home owner or licensed agent's signatur certify that in the performance of the work for which this permit is Issued, I shall not emloy persons subj Laws of California." Contractor's hiring or sub-contracting signature certifies the following! " I cer of the work for which this permit is issued, I shall eoploy persons subject to WORKMAN'S COMPENSATION Laws 4 MUST CALL 24 HOU ADVANC FOR ALL REQUIRE° INSPECTIONS AT UM 4611.3423. Cctqslete drawing at lower area p 4 Title 'dr ...t,„- Signed X _AB Joaquin County OrdiTiances, certifies the following; "I ct to WORKMAN'S COMPENSATION ify that in the performance California." THE APPLICANT ovided. -744,/74 2z-'/ oaf e PLOT PLAN (Draw to Scala) Scale ” to Names of s eta or roads nearest to or bounding the property. 4. Location of house Outline of the property, giving dimensions and North direction. proposed expansion Dimensioned outlines and location of all existing and proposed 5. Location of wells structures, including covered areas such as patios, driveways, the property or ad and walks. ,-,, C,/,'VEvv-i-T /,-;G% // z) awage disposal system or of sewage disposal systems. ithIn radius of 150 ft. on oining property. _,..._, r ______1, - DEPARTMENT USE ONLY i ' Date Application Accepted BY _ir.. Ar0A 4CY Date Pump Inspection By Date Grout Inspection BY 111 001, By ' Date IP Comments: 191/-124-1 4 g '1(0 . 0 A/54 Ifb Destruction Inspection dee 76/ ACCOUNTING ONLY: Of AID* FACN PE CODES FEE INFO AMOUNT REMITTED CNECKIICASN RECEIVED BY PATE PERMWSERVICE REQUJST NUMBER INVOICE 2-90 2-- (CO. 2V-00 dr;-5 173 4,1117bvi Tiiii/1 bo 3 '79 z...- --- -----------1C:YtIr - (1-0 "1id101 APPLICATION FOR WELLIPIIMP PERMIT - SAN JOAQUIN COUNTY PUBLft: HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201488 (209) 488.3420 J L 2 ? 1994 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH Application Is here by made to the San Joaquin county for a permit Co construct and/or Install the work de cri . h on is rt{tVilVAIV)titlq • (Complete le Tr011estel made in compliance with San Joaquin County Development Title, Chapter 9-1115.3 and the Stendarda of San 4oequin County Public wealth Services, Environmental Health Division. Job Address/or APNO Z /1:-C-15T Goi54;41/67-22,1 City NY/r0c;*-7-12,y / Owner's Name /2/7_,/91,1 Prc;1144C/S1 Address 2,/%15--/AP/4„SZ Lica Phone ff9/-47...r:" 0 Sub contractor 4%0-07-1WW7:C 64e45 Address 4_9// /,(//r)Pe-SY tic# Grqi. //513 Phone # 9/4 933' /e2/6,i s RECEIVED Parcel Site/APN# 51t-Pet Phone S 2o9-4'4 5.92 ewde.e.?....- Contractor 86 /6/4 Addresslyc.,/e,riL /9/64, Z4 -.Vat e, C4