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DEPARTMENT USE ONLY <br />ApplIcaBen AotteP1411 By r <br />Grout Inept:400n By _AAAVr4 <br />Delo <br />DIA. OF CONDUCTOR CASINO <br />DIA. OF WELL CASING <br />SPECIFICATION <br />)3,62_,A)6 Av 8 4' DIA. OF 14,44+-RPRIVA4T4ON <br />TYPE OF CASING/STEEL/PVC IVA <br />DEPTH OF GROUT SEAL V BC-at-4 1219 Mr-- <br />GROUT SEAL INSTALLED BY DR I <br />GROUT SEAL PUMPED: 14 Yee 0 No <br />LOCKING CHESTER BOX/STOVE PIPE <br />OTHER AIR ROTARY AUGER X CABLE <br />4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />5, LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />PLOT PLAN IDrew to Soelel Seale ' to <br />I. NAMES OF STREETS OR ROADS 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 />Pump Inspection By Delo <br />APPLICATION FOR WELLIPUMP 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) 468.3420 <br />COOSu-L-T-Aur r- itiA6 d07 464 5;11N1 4.4_1--44/73 4NN.P1RARTDR <br />SUB CONTRACTOR WE-ST .14si2 iv) ArT. D r-i A./ <br />>lig1541 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete In TrIpReats1 <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 WTTII SAN <br />JOAQUIN COUNTY DEVELOPMENT TITLE. CHAPTER 9-1 115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. .2. 08 <br />JOB ADDRESS/OR APNi /722 C.F. 40,9 STize-cr <br />OWNER'S NAME 5e-E- A.r7-4-C44-€-D L. 1 ST— ADDRESS <br />ADDRESS <br />D'eAci 5541 ADDRESS u„ 9 79 PHONE : 916 -4738-7276 <br />crry STOCKTOM PARCEL SIZE/APNE_PIRL9 D "' 0 I 10 Z. <br /> PHONE - -51 - 01_0 <br />/ 6 7 32. Pajin ere, Dk. tics it/i PHONE 411 640 -WY./ <br />REPLACEMENT WELL <br />0 WELL SYSTEM REPAIR <br />H.P. <br />OUT-OF-SERVICE WELL <br />MONITORING WELL I I <br />CROSS-CONNECT REPAIR <br />DEPTH PUMP SET FT. <br />GEOPHYSICAL WELL: <br />g OMER 14yd"tiCk/ fr_h [ <br />0 VAPOR EXTRACTION WELL: <br />FIRST WATER LEVEL <br />TYPE OF WELUPUMP: NEW WELL <br />INSTALLATION <br />0 New 0 Repel, <br />(TYPE OF PUMP) <br />0 DESTRUCTION: <br />CONSTRUCTION SPECIFICATIONS INTENDED USE 150140/6 <br />0 INDUSTRIAL <br />DOMESTIC/PRIVATE <br />PUBLIC/MUNICIPAL <br />IRRIGATION/AG <br />TYPE OF WELL <br />0 OPEN BOTTOM <br /> <br />0 GRAVEL PACK/SIZE <br />0 DRIVEN <br />ti4 OTHER 14 ifiro?v,A)41,-% <br />MONITORING <br />APPROX. DEPTH /31-1.erbCde- -Ft. <br />PROPOSED CONSTRUCTION/DRILUNO METHOD: MUD ROTARY <br />GROUT BRAND NAME <br />plA <br />NM- <br />CONCRETE PEDESTAL BY DRILLER: 0 Yee 0 No <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATION AND THAT THE WOFIK 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 />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 />ENE FOLLOWING: I CERTIFY THAT IN THE PERFORMANCE OF THE vvonK FOR WHICH THIS PERMIT IS ISSUED. I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CAI IFOFINI " THE APPUCANT MUST CALL 24 HOURS IN ADVANCE FOR AU. REGUIRED INSPECTIONS AT 12091 455-2423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Slanwd X <br />" <br />a/7 TItIe tat)tieflo 6-64 ./1.1-4-4frS Date iii 6rn <br />ACCOUNTING ONLY: AIDE FACE <br />... <br />PE CODES FEE INFO AMOUNT REMITTED CHECK/MASH RECEIVED BY DATE . PEFIMIT/SERVICE REOUEST NUMBER INVOICE <br />rS 0 *7- 1_, 6 5 ii-ez----- hirz- eit, ---7>r <br />Pub. Health Serv. - Enviro. 173 (3/96) <br />A <br />ER <br />>11 SOIL BORING 707744.- or Li pepth 10. <br />o MOO