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0 NEW WELL 0 REPLACEMENT WELL 0 MONITORING WELL # j"" 0 OTHER <br />0 INSTALLATION 0 WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELL # <br />El New 0 Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br />0 OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL S 0 SOIL BORING <br />P Ll re ri 14 010/4( /Cr, /Id., ././,; „2. arid i <br />TYPE OF WELL/PUMP: <br />(TYPE OF PUMP) <br />DESTRUCTION: <br />FORIRER <br />O <br />L , <br />10MERCROuN0 OvERNELO <br />UTILITIES II S. CLEARRNCLII <br />ROEND <br />RROFOSED SOIL ROAM <br />SOIL BORING <br />• LIONITORNE <br />0 LELLNOONE0 RCIN,OPIN0 reELL <br />w0N1' ROLE <br />lo.NN <br />OKREMARNFION S.R.LL <br />11•-•-•,"""""''' <br />OLD FENCE -NE <br />,SPWIGT <br />ND, FENCE LINE <br />SCALE <br />30 <br />SITE PLAN <br />757 EAST 1 TH STREET <br />TRACY, CALIFORNIA <br />ROEORMO MR <br />BJJ COMPANY <br />TRACY, CALIFORNIA <br />SMTH <br />Zfe <br />PAOWG <br />; FSSUE / ,S104 <br /> !A FIGURE 2 I <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 />C 0e/5/7 <br />PARCEL SIZE/APN# <br />OWNER'S NAME 13 j:_7 Cc . ir Ay 1 -171/1C-i , ADDRESS rat/3(.4 : C.7.6/6) PtioN?ilzi?77 -257k. <br />CONTRACTOR, cirl4i tA ::p1 Iiira, ikt-em. fa / re vi . • C ,--rp . ADDRE8812-k) 6raes ivi mvilci-—/,') 80( PHONEY 6W' 2-7.12. 1 <br />SUB CONTRACTOR V 4-111 Uri 1(1)1(y ; T./lc , ADDRES0.). f3C•4 4 ...c I i Rio 1/, ,tci., V it#77) 720 94%22?-3 79 —28/1 • <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete in Triplicate) <br />APPUCATION 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 APNW 76 7 r • tie veit sr-r‹e 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 />0 OPEN BOTTOM <br />0 GRAVEL PACK/SIZE <br />0 DRIVEN <br />0 OTHER <br />2-3 FT- <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF WELL EXCAVATION <br />TYPE OF CASING/STEEUPVC <br />DEPTH OF GROUT SEAL <br />GROUT SEAL INSTALLED BY -)pak::. trcr <br />GROUT SEAL PUMPED: CI Yes 0No <br />LOCKING CHESTER BOX/STOVE PIPE <br />A <br />DIA. OF CONDUCTOR CASING <br />DIA. OF WELL CASING Z rIC <br />SPECIFICATION F CV:7\ <br />GROUT BRAND NAME64,110•‘,./"</-SseisI4-1 <br />CONCRETE PEDESTAL BY DRILLER: CI Yee El No S <br />PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY <br /> <br />AIR ROTARY AUGER <br />CABLE OTHER <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:10ERTIFY 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 />CALIFORNIA. THE APPUCANT MUS CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 120914684423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Signed X Title PA° an/Lalcik. <br />PLOT PLAN (Draw to Scale) Scale 45 " to <br />NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 5110 A In <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 A C DATIfIC nen/cm/Avg A tAtS \Mel C <br />Date <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 />THE PROPERTY OR ADJOINING PROPERTY. <br />ame. <br />DEPARTMENT USE ONLY <br />Date 4:1110(941 <br />Date 15fq <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By 11-k "ke <br />Comments: od—k 4 14/ <br />Date Pump Inspection By <br /> <br />\ 1,,t LA, S <br />Date <br />ACCOUNTING ONLY: AIDS FACS <br />PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECEIVED BY DATE . PERMIT/SERVICE REQUEST NUMBER INVOICE <br />_ <br />.> .11 <br />Ct., <br />q i ielqi, <br />—_,