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PAYMENT <br />RECEIVED <br />DEC 22 2003 <br />SAN JOAQUIN COUNTY <br /> EAALL„Nr <br />EAU E <br />A <br /> DEPARTMENT USE ONLY <br />thy Dato Pump Inspection By <br />PLOT PLAN IMPA, to 8o4e1 Boolo <br />I. NAMES or STREETS on nonoe NEAREST TO on BOUNDING THE PROPERTY. <br />OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. <br />DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED <br />ernucrunEe, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. <br />LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />S. LOCATION OF WELLS WITHIN RADIUS OF ONEHUISORED FIFTY FT. <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />IC <br />D ' oeSmIlon Ineesoiton By • (.<1 <br />Applies:Ton Accepted By <br />Groot Inspection By <br />APPLICATION FOR WELL/PUMP PERMIT <br />;AN JOAQUIN COUNTY PUBLIC HEALTH SERVI1 <br />ENVIRONMENTAL HEALTH DIVISION <br />304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br />(209) 468-3420 <br />NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br />SAN JOAOUIN COUNTY C HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADVREUR 1 e / 71, cirys-/D.,K3-6,1 C CA. PARCEL SIZEJAPN# 3,76/ A• L <br />ovvertn's NAM X Adae '51> ADDRESS 7 )I Ai. Amds......seaA Sr PHONE # 933—• 7005 coN.Tone-C4k•• k ADDRESS 0324 f/i SI— 6 IA& i" 413C. 57/54o PHONE • 1(0276% <br />14-3"1 PHONE <br />SUB CONTRACTOR ADDRESS UCI <br />0 WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR <br />0 MONITORING WELL It <br /> <br />0 VAPOR EXTRACTION WELL I <br />0 OTHER <br />DEPTH PUMP BET FT. FIRST WATER LEVEL <br />0 OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL # <br /> <br />0 TOIL BOOING <br />5 IrIC 6 3i-e2( X 0 DESTRUCTION: <br />CONSTRUCTION SPECIFICATION"... <br />DIA. OF WELL EXCAVATION CO" /4C Al <br />GROUT SEAL INSTALLED BY De (-IIG <br />GROUT SEAL PUMPED: 0 Teo ON. <br />PROPOSED CONSTAUCTION/D1VLUNG METHOD: MUD ROTARY AIR ROTARY AUOER CABLE X OTHER <br />LOCKING cumin BOX/STOVE PIPE <br />$ <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS. AND RULES AND <br />REGULATIONS OF THE RAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH <br />THIS PERMIT 18189U 13, I SHALL NOT NS SUB CT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA. • CONTRACTOR'S nmotro OR SUB CONE RACTING SIGNATURE CEITTIFI <br />CALIEORNIA.' T THE vvonn FOR WHICH THIS PERMIT 18 ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWN X <br />S FOR ALL REQUIRED INSPECTIONS AT MINH 411S.3421. COMPLETE onnvrimo AT LOWER AREA PROVIDED. <br />Signed IT • TIlle <br /> DR. -02C2 <br />Comms4o1 <br />ACCOUNTING ONLY: AID/ FACT <br />PE CODES FEE INFO 1 AMOUNT REMITTED C1.21S3AA1111 RECEIVED BY EAT PERMIT/SERVICE REQUEST NUMBER INVOICE / A A _- /0._ o. Pp- '00 <br />(t3 -7 16/ ( J ç() -I crw5- 4,, iL., 5/Zoo36 1-ho <br />Pub. Health Serv. - Envlro. 173 (1/97) <br />'Complain In TripIkulel APPEIATIflJ4 IS IIERE BY MADE TO THE SAN JOA01/IN COUNTY FOrERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED. T1118 APP IANCE WITH SAN LICATION 18 MADE IN COMPL - JO AAJIN COUNTY DEr,_,Er TITLE. CHM; B 111 12 T 1E STANDARDS OF PUBLI <br />NN I I/ 4coo3 <br />TYPE OF WELL/PUMP( 0 NEW WELL <br />0 INSTALLATION <br />New 0 Repel/ <br />,0 REPLACEMENT WELL <br />(TYPE OF PUMP) <br />INTENDED USEUSE <br />o INDUSTFIIAL <br />DOMESTIC/PRIVATE <br />0 PUBLIC/MUNICIPAL <br />0 IRRIGATION/AO <br />0 MONITORING <br />APPROX. DEPTH <br />TYPE OF WELT. <br />0 OPEN BOTTOM <br />El GRAVEL PACK/SIZE TYPE OF CATIINCUSTFEUPVC <br />0 DRIVEN DEPTH OF GROUT SEAL 67,7 75 <br />OTHER <br />DIA. OF CONDUCTOR CARING /4.41- <br />A <br />DIA. OF WELL CASING Zie / Ile- 46 D p <br />SPECIFICATION /AP' & IX <br />onoor BRAND NAME P444-1.C..1.14.._ Id. E <br />CONCRETE PEDESTAL BY DRILLER: 0 Yoe ON. <br />HIE FOLLOWING