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DIA. OF WELL EXCAVATION <br />TYPE OF CASING/STEEUPVC <br />DEPTH OF GROUT SEAL <br />GROUT BRAND NAME GROUT SEAL INSTALLED BY <br />CABLE OTHER <br />GROUT SEAL PUMPED: El Yea 0 No CONCRETE PEDESTAL BY DRILLER: 0 Yes 0 No <br />LOCKING CHESTER BOX/STOVE PIPE <br />AIR ROTARY AUGER <br />DEPARTMENT USE ONLY • <br />Application Accepted By Date r? ('=' Area ' <br />Data Pump Inspection By <br />• <br />Date 611- / et Grout Inspection By AN.)/C-1. <br />INTENDED USE <br />INDUSTRIAL <br />DOMESTIC/PRIVATE <br />PUBLIC/MUNICIPAL <br />IRRIGATION/AG <br />MONITORING <br />APPROX. DEPTH <br />CONSTRUCTION SPECIFICATIONS TYPE OF WELL <br />0 OPEN BOTTOM <br />0 GRAVEL PACK/SIZE <br />0 DRIVEN <br />0 OTHER <br />PROPOSED CONSTRUCTION/DRILUNG METHOD: MUD ROTARY <br />DIA. OF CONDUCTOR CASING <br />DIA. OF WELL CASING <br />SPECIFICATION <br />A <br />CALIFORNIA." THE APPUCANT MUST CALL / 24 UR8 ADVANCE FOR ALL REQUIRED INSPECTIONS AT 1209) 488-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />PP0-)g'or MAk4 Ep Date Title <br />LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />ON THE PROPERTY OR ADJOINING PROPERTY. <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 <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 />0 <br />.----- <br />Signed X <br />PLOT PLAN (Draw to Scale) Scale " to <br />NAMES OF STREETS OR RO S 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 />IL <br />Destruction Inspection By <br />Comments: - IA) ,Ztt4i. 'n)-( etu et, OA 4,4' y, <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# 9e/7 North /AO/Le/It 9q CITY -'/62 Ck71c11 PARCEL SI E/APN# <br />OWNER'S NAME C lie i/on/ ADDRESS A °"&X 5-'°° 5.41//e/01 PHO‘ECie) <br />CONTRACTOR V a ki AR/a/N6 ADDRESS/17./)X5/ etoyari ,c,,Lca% ,,RNE <br />SUB CONTRACTOR -7-a(r -70 /1//r - keVELOPNII— PV7c ADDRESS /00 /(eCdOM XjA 135'1960/ <br />TYPE OF WELL/PUMP: 0 NEW WELL <br />0 INSTALLATION <br />0 New 0 Repair <br />REPLACEMENT WELL <br />WELL SYSTEM REPAIR <br />H.P. <br />MONITORING WELL # <br />CROSS-CONNECT REPAIR <br />DEPTH PUMP SET FT. <br /> <br />OTHER <br /> <br />VAPOR EXTRACTION WELL # <br />FIRST WATER LEVEL <br />(TYPE OF PUMP) <br /> <br />OUT-OF-SERVICE WELL <br /> <br />O GEOPHYSICAL WELL # <br /> <br />O SOIL BORING <br />DESTRUCTION: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECKCCASH . .....- RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />(; tie ) kV_ ltzz .--;-)z70 -2,C`17