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0 NEW WELL <br />El INSTALLATION <br />0 New 0 Repair <br />TYPE OF WELL/PUMP: <br />(TYPE OF PUMP) <br />0 DESTRUCTION: <br />REPLACEMENT WELL <br />WELL SYSTEM REPAIR <br />H.P. <br />OUT-OF.SEFIVICE WELL <br />OTHER <br /> <br />VAPOR EXTRACTION WELL <br /> <br />FIRST WATER LEVEL <br /> <br />0 <br />/X SOIL BORING <br /> <br />MONITORING WELL <br />CROSS-CONNECT REPAIR <br />DEPTH PUMP SET PT. <br />GEOPHYSICAL WELL 0 <br />APPLICATION FOR WELLIPUMP PERMIT <br />!,1!‘? JOAQUIN COUNTY PUBLIC NEALPI SERV <br />ENVIRONMENTal PEALTP 011OSION <br />P.O. BOX 38B, 304 EAST WEBER AVENUE, STOCKTON, CA 95201-388 <br />(203) 468-3420 <br />NOPHIEFUTIDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete in Triplicate) <br />AppticATIoN Is HERE By MADE TO THE SAN ,IcADUIN 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 AM. /'Z'E, 7 . A/A:Jag <br />CITY .14t1 <br />CONTRACTOR 24 iv <br />OWNER'S NAME /-41.) ADDRESS -47, 20e 4Ceiry <br />*We CONTRACTOR 7E ( 11350 <br />n1,10111=1M13113111111G.MCOT <br />PARCEL SIZE/APNO <br /> <br />PHONE <br /> <br />MPoier Pab-K ADDRESS <br />ADDRESS _..,,v4erivq-/-/ps-..., 1 ICS PHONE rf-/-----?-99---Aie <br />co rd. <br />I /C.2 Y PHONE a fee„:701:- :WO <br />INTENDED USE <br />INDUSTRIAL <br />DOMESTIC/PRIVATE <br />PUBLIC/MUNICIPAL <br />IRRIGATION/AG <br />0 MONITORING <br />APPROX. DEPTH <br />TYPE OF WELL <br />0 OPEN BOTTOM <br />0 GRAVEL PACK/SIZE <br />0 DRIVEN <br />0 OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF WELL EXCAVATION <br />TYPE OF CASING/STEEL/PVC <br />DEPTH OF GROUT SEAL <br />GROUT SEAL INSTALLED BY <br />DIA. OF CONDUCTOR CASING <br />DIA. OF WELL CASING <br />SPECIFICATION fl <br />GROUT BRAND NAME <br />GROUT SEAL PUMPED: 0 Y.,.O N, CONCRETE PEDESTAL BY DFULLER: 0 Yee 0 No <br />LOCKING CHESTER BOX/STOVE PIPE <br />PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CAERE OTHER4.62,4944_,c_ <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE W1TH SAN JOAOU1N 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 18 ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMFIENSAllON 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 18 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CALIFORNIA.' THE APPUCAFIT MU CAU. 24 HOURS IN ADVANCE FOR AU, TrEnUIRED INSPECTrt'A /sT '2012) FRS-423. COA'PLETE DRAWING AT CWER AREA MON. <br />X <br /> <br />eCe <br /> <br />.441C- <br /> <br />Tme eyj 7 -P-7,1,t/ereen Date - /7-Ea, <br /> <br />4 PLOT PLAN (Draw to Solge) Scala '10 <br />NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING TlIfF 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 />LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />.6 <br /> J <br />S. <br />7:4111 <br />(trout truttoct., By <br />AppitlotIon Accopt&S <br />0 <br />1064 74116 <br />'t20 eBo9--k1 1-0 <br />OFPART/AENT USE ONLY <br />Oslo <br />Date Pump Inspection By Date <br />Gaztrucdon Dato <br />corm„... Ti rizavieri ctuthcery,ftan fbv- ScAN4dA.Agd 9.4,1 12-23-1(0 <br />ACCOUNTING ON: <br /> <br />I AIDE <br />FACF <br />DATE PERMIT/SETIVICE REQUEST NUMBER INVOICE <br />tv20.1v o <br />----t <br />SP‘00\\It,0— f <br />PE CODES FEE INFO <br /> —1 <br />AMOUNT REMITTED C HECK/ /C ASI I RECEIVED RV <br />)2.4 51 - 40.