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GROUT SEAL PUMPED: 0Y.. ONe CONCRETE PEDESTAL BY DRILLER: 0Y.. 0 No <br />LOCKING CHESTER BOX/STOVE PIPE <br />CONSTRUCTION SPECIFICATIONS <br />4/1 DIA. OF WELL CASING <br />DIA. OF WELL EXCAVATION <br />TYPE OF CASINO/STEEL/PVC <br />DEPTH OF GROUT SEAL <br />GROUT SEAL INSTALLED BY GROUT BRAND NAME <br />TYPE OF WELL <br />0 OPEN BOTTOM <br />El GRAVEL PACK/SIZE <br />0 DRIVEN <br />0 OTHER <br />DIA. OF CONDUCTOR CASINO VA <br />A/A <br />I <br />t- 76.1 ,t• f1 1 .1 SPECIFICATION <br />APPLICATION FOR WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201-388 <br />(209) 488-3420 <br />NON•REFUNDABLE PERMIT EXPIRES 1 YEAR FROM PATE 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 16 MADE IN COMPUANCE WITH SAN <br />JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1 1 1 5.3 AND THE STANDARDS OF SAN JOAOU1N COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR APNS tAJ. se 41 a.i+ CITY 11/414 PARCEL SIZE/AM/V293'. Of° <br />O: I ADDRESS 42 7 3 7 LAJ: PHONE 0420028'....S"..7 Liao <br /> ADDRESS 1(1°' 140Sftle'TIIC, <br />ti ed ( 4 lic <br />37 — 0O C ONE (*4)4("C‘—" <br />ADDRESS R.) 225/ 44 u e,b>707 <br />. <br /> PHONE 040 <br />OWNER'S NAME <br />CONTRACTOR <br />SUB CONTRACTOR <br />5 geoe <br />TYPE OF VVELUKIMP: <br />(TYPE OF PUMP) <br />0 DESTRUCTION: <br />INTENDED USE <br />INDUSTRIAL <br />DOMESTIC/PRIVATE <br />0 PUBLIC/MUNICIPAL <br />IRRIGATION/AG <br />MONITORING <br />APPROX. DEPTH <br />0 NEW WELL 0 REPLACEMENT WELL 0 MONITORING WELLS 0 OTHER <br />0 INSTALLATION 0 WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELLS <br />0 New 0 Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br />0 OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELLS ta, SOIL BORING 6e0 6D4ICuPSb1 Efil` PROPOSED CONSTRUCTION/ORIWNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br />THIS PERMIT 18 ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA. CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW 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 WOW FOR WHICH <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 />TCALIFORNIA.* THE APPUCAN UST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 19145-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Signed X 12151 Title fl Date '2 . <br />PLOT PLAN (Drew to Scale) Scale <br />NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. <br />OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. <br />DIMENSIONED OUTUNFS AND LOCATION OF ALL EXISTING AND PROPOSED <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. <br />to <br />4. 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 />ApplIcstIon Accepted By <br />Grout Inspection By / <br />„ <br />DEPARTMENT USE ONLY <br />c/`';' Date ' Pump Inspection By <br />Del. 6/* Area - <br />Date <br />DeetructIon Inspection By <br /> Data <br />Comments: <br />ACCOUNTING ONLY: AIDS <br /> FACO <br />PE CODES FEE INFO AMOUNT REMITTED CHECKS)CASH RECEIVED BY DATE PERNIIT/SERVICE REQUEST NUMBER INVOICE <br />,- <br />- , ---f37 poL0-)gy,7 CI