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TYPE OF WELL/PUMP: 0 NEW WELL <br />0 INSTALLATION <br />0 New 0 Repair <br />TYPE OF PUMPI <br />0 REPLACEMENT WELL <br />0 WELL SYSTEM REPAIR <br />0 OW-OF-SERVICE WELL <br />0 MONITORING WELL 0 <br /> <br />CROSS-CONNECT REPAIR <br />DEPTH PUMP SET FT. <br />GEOPHYSICAL WELL f <br /> <br />0 DESTRUCTION: <br />A <br />INTENDED USE <br />0 INDUSTRIAL <br />0 DOMESTIC/PRIVATE <br />0 PUBLIC/MUNICIPAL <br />0 IRRIGATION/AO <br />MONITORING <br />APPROX, DEPTH <br />TYPE OF WELL <br />0 OPEN BOTTOM <br />El GRAVEL PACK/SIZE <br />0 DRIVEN <br />El OTHER <br />0 - <br />APPLICATION FOR WELLIPUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P 0 BOX 389, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201.388 <br />(209) 459-3420 <br />5-411 <br />!1UL 7 1995 <br />ENVIRONM1 AENIAL HEALTH NON•REFUNDADLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br />(Complete in Triplicate) PERMIT/SERVICES APPUCATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE VVORK DESCRIBED. THIS APPUCATION IS MADE IN COMPUANCE WITH SAN <br />CITY S'itC lorin <br />ADORERS a 5s-3-ow/A B Ctif Om PHONE,O 51 p75 <br />ADDRESS au ) b37 PHONE Ro7-37Y-020 <br />El OTHER <br />0 VAPOR EXTRACTION WELL <br />FIRST WATER LEVEL <br />X SOIL BORING <br />PRC0 PrbtliAt4-3 Conpcm," OWNER'S NAME <br />CONTRACTOR LAI odcwrol Dr;111” <br />SUB CONTRACTOR <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 ARNE 321 )4• Gt 6.rrn ,c. 54(eci— <br />ADDRESS <br /> <br />PHONE <br /> <br />PARCEL SIZE/APNE <br />TYPE OF CASING/STEEUPVC DIA. OF WELL CASING 0 <br />DEPTH OF GROUT SEAL SPECIFICATION A -.. <br />GROUT SEAL INSTALLED BY colour BRAND NAME P614144 44 E f' , <br />GROUT SEAL PUMPED: 0 Yea El .c. CONCRETE PEDESTAL BY DRILLER' 0 Y.. Os. $ <br />LOCKING CHESTER BOX/STOVE PIPE C.") <br />S_i.... <br />CONSTRUCTION SPECIFICATION <br />DIA. OF WELL EXCAVATION g rl CJA <br /> <br />DIA. OF CONDUCTOR CASING <br /> <br />PROPOSED CONSTRUCTION/DRILUNG METHOD: MUD ROTARY AIR ROTARY AUDER____X_ CABLE OTHER <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULED AND <br />REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR IJCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WON( FOR WHICH <br />THIS PERMIT 18 ISSUED. I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR BUS-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 APPLICANT MUST C 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT I2001 465-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />!Boned X C4.1.(44 1 • TM. 6rda51.3 /fr Dots g- Y-9 5- <br />PLOT PLAN Draw to Sools1 Seal. ' to <br />NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. <br />OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. <br />DIMENSIONED OUTLINES AND LOCATION OF ALL EX/STING AND PROPOSED <br />STRUCTURES, 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 />N. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />St-C, Ct---RadA-0-eA Jor(C/910, <br />Application Accept./ By <br />Groot inspection By <br /> <br />Destruction Impaction By <br />Comments: <br /> <br />TMETIT USE ONLY <br />afdefki/.\-/VD"" Area <br /> <br />Dots pomp !mat/ration BY <br /> <br />DPI <br /> <br />Des <br /> <br />ACCOUNTING ONLY: MD/ FACE <br />FEE INFO AMOUNT REMITTED CICIA/CASII RECEIVED BY OAT/ PERMIT/SERVICE REQUEST NUMBER INVOICE <br />WM 1 g?- 6"-/37 JYCI 110S - 0704, <br />-i--- .-.------i-R 6 0 0 6 --6 . I— . - . •,'n