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ja NEW WELL 0 INSTALLATION 0 New 0 Repair TYPE OF WELL/PUMP; (TYPE OF PUMP) 1-1 L-I DESTRUCTION: DIA. OF WELL EXCAVATION TYPE OF CASING/STEEL/PVC DEPTH OF GROUT SEAL tO PQC- cati. 2_ Is- AIR ROTARY AUGER "SC. CABLE OTHER Title p 05„1 -( C " Sierred X Date ( & EC( (.• f E A- TrAc i+ DEPARTMENT USE ONLY Date /9..5 Are. 6.Fy APPLICATION FOR WELLIPUMP PERMIT tv,P N JOAQUIN COUNTY PUBLIC HEALTH SERVICO ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 8520_1:7, (209) 466-3420 Th NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED — P. ppi APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR AM.' S' S- tvra,tcro,,,, tA) F- r c- r-() A crry .S.re rs OWNER'S NAME Vs-/ ''t.Ritiv s Pis V(1- TA /1/4) CONTRACTOR '1A)E. 1- E SUB CONTRACTOR (Comst.n Triplicate) - 5? ADDRESS PARCEL SIZE/APNS C-AC S C-C CA ei FIVE PHONE • (02-3S 2- 13Sc9 ADDRESS CU ‘A'T (Nee. RD, uc# 5-1 2 1912 psfoNE #61 /6 .1" ) s ADDRESS lid PHONE I OTHER WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELL, H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 3 1 f OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL REPLACEMENT WELL El, MONITORING WELLS /1114 e SOIL BORING 0 INTENDED USE INDUSTRIAL DOMESTIC/PRIVATE o PUBUC/MUNICIPAL IRRIGATION/AG 21 MONITORING APPROX. DEPTH CONSTRUCTION SPECIFICATIONS GROUT SEAL INSTALLED BY %.,1E. GROUT SEAL PUMPED: El Yee ONe LOCKING CHESTER BOX/STOVE PIPE DIA. OF CONDUCTOR CASING DIA. OF WELL CASING 11.— 1 IL) /4 SPECIFICATION C. 12 / 5-C iZ GROUT BRAND NAME PUrZ-' I E.41 CONCRETE PEDESTAL BY DRILLER: Yoe 0 Ne PROPOSED CONSTRUCTION/DRILUNG METHOD: MUD ROTARY TYPE OF WELL 0 OPEN BOTTOM El GRAVEL PACK/SIZE .41 / 2- 0 DRIVEN 0 OTHER L . I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WU_ BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 1 CERTIFY THAT IN THE PERFORMANCE OF THE VVORK FOR WHICH 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 THE FOLLOWING: I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPUCANT MUST CALL 24 HOIAUI IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12051 469.1423. COMPLETE DRAWING AT LOWER AREA PROVIDED. PLOT PLAN (Draw to Scale) Scale L NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 2 OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED EXPANSION OF SEWAGE DISPOSAL SYSTEMS. B. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. ON THE PROPERTY OR ADJOINING PROPERTY. ' to Date Application Accepted By Grout Inspection By Date Pump Inspection By II ACCOUNTING ONLY: I AIDS PACS p -->7 PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECEIVED BY DATE PERMIT/SERVICE INVOICE REQUEST-3VMM j5e)(1K?--- / /4--1-- F/05 I'e 2 7,6() M 45P / Destruction Inspection By Comments: Date eYk. ee,Le-iY A-66: dzsr-c__