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LIC# PHONE # <br />OTHER <br />VAPOR EXTRACTION WELL # <br />FIR WATER LEVEL 0 <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF WELL EXCAVATION <br />TYPE OF CASING/STEEL/PVC <br />DEPTH OF GROUT SEAL <br />DIA. OF CONDUCTOR CASING <br />DIA. OF WELL CASING o <br />SPECIFICATION <br />GROUT SEAL INSTALLED BY <br /> GROUT BRAND NAME <br />GROUT SEAL PUMPED: El Yee El No CONCRETE PEDESTAL BY DRILLER: El Yee 0 No S <br />LOCKING CHESTER BOX/STOVE PIPE S <br /> AIR ROTARY AUGER CABLE OTHER <br />Signed X Title Date <br />LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />PLOT PLAN (Draw to Scale) Scale - to itt, <br />NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. <br />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 />L.0 <br />N <br />Lee-elliatAr, . <br />° <br />APPLICATION FOR WELLIPUMP 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 9-1 1 1 5.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR APN4 121- R-E(' -frot—c„ <br />OWNER'S NAME U ri (.7---t,t—t-- (.....1 ADDRESS <br />CONTRACTOR 4 01 L t2 171.JA.,--,& c 'AA/1 (-/----<) ADDRESS <br />SUB CONTRACTOR <br />TYPE OF WELLJPUMP: 0 NEW WELL 0 REPLACEMENT WELL 0 MONITORING WELL # <br />0 INSTALLATION 0 WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR <br />El New 0 Repair H.P. DEPTH PUMP SET FT. <br />(TYPE OF PUMP) <br />0 OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL <br />ADDRESS <br />PARCEL SIZE/APN# <br />ONE # (GIO) If <br />Lic#L41- CA-LiAt-pHoNE a4icts --t-2,3 I <br />DESTRUCTION: XL mon \r <br />INTENDED USE <br />INDUSTRIAL <br />DOMESTIC/PRIVATE <br />PUBLIC/MUNICIPAL <br />IRRIGATION/AG <br />MONITORING <br />APPROX. DEPTH <br />TYPE OF WELL <br />El OPEN BOTTOM <br />0 GRAVEL PACK/SIZE <br />0 DRIVEN <br />0 OTHER <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 <br />REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH sd`, <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 PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CALIFORNIA.- THE APPUCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12091468-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Application Accepted By [sIKVVII34-, <br />Grout Inspection By Date 6/7k <br />DEPARTMENT USE ONLY <br />Pump Inspection By <br />Date izAfkr Ar.tr , 0 <br />Data <br />Destruction Inspection By Date <br />Comments: (1111 Ps) <br />ACCOUNTING ONLY: AIDA, FAC4 <br />PE CODES FEE INFO AMOUNT REMITTED <br />-- .." <br />0HESKP/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />C.3q0 P' . of , <br />t7 e - - <br />— - .4-