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vL, , vto I • <br />MW-3 <br />99 <br />ND<67.5940<0.5 <br />NOT MEASURED <br />DISPENSER <br />ISLANDS <br />PIS -3 <br />I- I I I <br />I I <br />ICIti - nik3-1 I <br />MW-1 LPII V -2-, -4- , <br />ND<O. NO<0. <br />Y..20.ps9 <br />v <br />., UN ROUND <br />FUEL TANKS <br />NOT MEASURED <br />IliellEE231". <br />15111111 <br />TRANSPOTILIEN <br />...xsin1M8W0_120-02 0 ___ILAMIW1651.0 610 NOCO.D1 8.1 <br />NOT MEASURED 3.9 <br />DRIVEWAY <br />NINE-WAY <br />MW-4 <br />74 <br />yi)slUND(0.5 <br />NO<0.51-13— <br />NOT MEASgRED <br />r <br />I I <br />L J <br />Uf DERGROL/NO <br />USED OIL TANK F10-2 <br />APPLICATION FOR WELL(PUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P 0 BOX 388, 445 N. SAN JOAQUIN ST.. STOCKTON, CA 95201.388 <br />(2091 468.3420 <br />NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br />(Complete In Triplicate) <br />APPLICATION 19 NERE BY MADE TO THE SAN JOAOUIN COUNTY TOR A PERMIT TO CONSTRUCT AND/011 INSTALL THE WORK DESCRIBED THIS APTIJCATION IS MADE IN COMPLIANCE WITH SAN <br />JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1115 3 AND TIIE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES. ENVIRONMENTAL HEALTH DIVISION. <br />(iC-) E 31 V a milt,- Di, C,k21 k\./ PATICEL SIZE/APNE <br />JOB ADINIESS/OR APN/ 3 2 0 2- <br />OVVNEFES SL.0 A)Pj A)13 C. ADDRESS CO I 511 5-i t.0 r <br />CONTRACTOR CA4 (--0 11,13 n. ADDRESS <br />SUB CONTRACTOR ADDRESS <br />0 OTHER <br />la VAPOR EXTRACTION WELL - I <br />FIRST WATER LEVEL <br />0 OUT-OF-SERVICE WELL <br />0 DESTRUCTION: <br />A <br />DIA. OF WELL EXCAVATION 6 DIA. OF CONDUCTOR CASING I\I fir 0 <br />TYPE OF CASING/STEEIJPVC f V C. DIA. OF WEU. CASING 2 " D <br />DEPTH OF GROUT SEAL (.0 SPECIFICATION S C... <br />ki <br />t 0 • go fy c, R <br />carom SEAL INSTALLED BY Tr / 011-4...• GROUT BRAND NAME .--- E <br />GROUT SEAL PUMPED: DV.. 0 No CONCRETE PEDESTAL BY DRILLER: 0 y..g No .5 <br /> <br />1.0C1(113 C1--------biESTER 9 r/STOVE PIPE S <br /> Ain ROTARY AUGER X <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND num AND <br />REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR UCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EM OY FEB NS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING on SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: ' I CERTIFY THAT IN TI MANCE OF 15 WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' T 7CANT ST): 24 <br />Signed X <br />ID IN ADVA C...7.1•11 AU. REWIRED INSPECTIONS AT I2Vq 4911.3421. EDCOMMET BAWING AT LOWER AREA PRO DED <br />'\ ‘j/ <br />litid TM* Lif/ni 4 / Ki lji. C4I' G.e,i li 1'4 ..,. <br />PLOT PLAN IDrow to &WO Boole " to <br />NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. <br />2. OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. <br />DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. <br />2-500 PHONE 42 1.1 t),141.- o <br />UCS 9 2( !IONE (5- ‘-/ L <br />03LPHONE / (111b <br />1° <br />)1)10/0-_33u <br />C57 <br />LICE <br />TYPE OF WELLIPUMP: 0 NEW WELL <br />INSTALLATION <br />0 New 0 Repel, <br />REPLACEMENT WELL <br />0 WELL SYSTEM REPAIR <br />H.P. <br />(TYPE OF rUmn1 <br /> <br />El MONITORING WELL S <br />0 CROSS-CONNECT REPAIR <br />DEPTH PUMP SET FT. <br />0 GEOPHYSICAL WELL 0 SOIL BORING <br />INTENDED USE <br />0 INDUSTRIAL <br />0 DOMESTIC/PRIVATE <br />0 PUBLIC/MUNICIPAL <br />o <br />TYPE OF WELL <br />0 OPEN BOTTOM <br />0 GRAVEL PACK/SIZE <br />0 DRIVEN <br />0 OTHER <br />CONSTRUCTION SPECIFICATIONS <br />o Txgro, L.4" 0 N' <br />APPROX. DEPTH I / <br />PROPOSED CONSTRUCTION/DI/KUNO METHOD: MUD ROTARY CABLE OTHER <br />4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />ON THE PROPERTY on ADJOINING PROPERTY. <br />ArrolIcolIon Acooprod Seyge)"\-2 <br />Grout Int000llon By „I - 0.,./ 7-1 <br />Dottroollon Impaction By <br />pump Impaction By <br /> A D.,.1) 7/ CI - <br />DEPARTMENT USE ONLY <br />Dote <br />Conwnonto: <br />ACCOUNTING ONLY: <br />— <br />AIDE FACE <br />PE CODES FEB INFO AMOUNT REMITTED /CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMMI INVOICE <br />3f0 i a tlis <br />7.VIDDIAGraii..„