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0 OPEN BOTTOM <br />jaGRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC <br />0 DRIVEN <br />0 OTHER <br />TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br />/C) C( <br />L- <br />V/rt-I e4.,P DEPTH OF GROUT SEAL <br />eit GROUT SEAL INSTALLED BY GROUT BRAND NAME rtict•-() C ite, t E <br />DIA. OF WELL EXCAVATION <br />A <br />I I <br />DIA. OF CONDUCTOR CASING -4- , <br />DIA. OF WELL CASING _2" , / <br />D <br />SPECIFICATION R <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />L'A-6G1(' <br />Date Area < <br />Data i 2-- Pump Inspection By Data <br />Date <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 />(209) 468-3420 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete in Triplicate) <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 MADE IN COMPLIANCE WITH SAN <br />JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR APN# &a/4F Atirti - CITY ...-C--5r)( (1--e/vi PARCEL SIZE/APN# //It_ <br />OWNER'S NAME /4;,0 t.(7/1-h-tifire <br /> <br />ADDRESdel., 40 OKI-72-V! 4tCr ,-57CC-Kir '-i l3PHoNE <br />CONTRACTOK;k7.41-‘0(C/i-Z. , 7 — / <br /> <br />ADDRESS/G%:3 a' /441.4 ti--/ (41 1(4 LIC# <br />SUB CONTRACTOR-4-4 I1'/' hi ; _ LIC#c' 272,C re.", PHONE #2g5 - 7371 ADDRESSIV/ , SriCilre;* <br />jr'61— <br />PHONE * <br />TYPE OF WELL/PUMP: 0 NEW WELL <br /> <br />O REPLACEMENT WELL <br /> <br />O MONITORING WELL # Vi OTHER A ill_ t <br />0 INSTALLATION <br /> <br />O WELL SYSTEM REPAIR <br /> <br />O CROSS-CONNECT REPAIR NI VAPOR EXTRACTION WELL # ../ <br />0 New 0 Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0 <br />(TYPE OF PUMP) <br />OUT-OF-SERVICE WELL <br /> <br />O GEOPHYSICAL WELL # 0 SOIL BORING <br />0 DESTRUCTION: <br />INTENDED USE <br />INDUSTRIAL <br />DOMESTIC/PRIVATE <br />PUBLIC/MUNICIPAL <br />IRRIGATION/AG <br />„la MONITORING <br />APPROX. DEPTH <br />PROPOSED CONSTRUCTION/DRILUNG METHOD: MUD ROTARY <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 CO <br />REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br />THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA. CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: " I CERTIFY THAT IN THE PERFDRMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS 0 <br />CALIFORNIA.:--TRE A MUST CALL 24 UFt6 IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT I 091468-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Signed X Title P/2-IU 4.Z b it .4ft-A <br />PLOT PLAN (Draw to Scale) Scale to <br />. NAMES OF STREETS OR ROADS NEAREST YO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />. OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br />DEPARTMENT USE ONLY <br />GROUT SEAL PUMPED: El Yes 0 No CONCRETE PEDESTAL BY DRILLER: El Yee 0 No <br />LOCKING CHESTER BOX/STOVE PIPE <br />AIR ROTARY AUGER CABLE OTHER <br />Date /,,e1, <br />F <br />Comments: KO <br />1 <br /> A -.../o) <br />ACCOUNTING ONLY: AID# F AC # <br />PE CODES FEE INFO AMOUNT REIVIITTED CHECKCCASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />-Yr' / pr, (/ <br />, _._... <br />( Sotoo`-b614