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REPLACEMENT WELL <br />0 WELL SYSTEM REPAIR <br />H.P. <br />OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELLS <br />DEPTH PUMP SET FT. <br />)(MONITORING WELL S <br />0 CROSS-CONNECT REPAIR <br />DIA. OF CONDUCTOR CASINO J/4 <br />01A. OF WELL CASINO 0 4 4 <br />SPECIFICATION SC_ 7, Dv I C.) c.c. <br />GROUT BRAND NAME Isj <br />CONCRETE PEDESTAL BY DFIILLER:jaYso ON. <br />LOCKING CHESTER BOX/STOVE PIPE Fl )6p.I NI 0, 3 T tvc-ft er:. X <br />AIR ROTARY AUGER is CABLE OTHER <br />GROUT SEAL PUMPED: VI,Yos 0 No <br />ty3Ar <br />ertp <br />ddiva.uin <br />1 <br />AvolleatIon Aeoftott,1 By <br />/ <br />Grout InopnctIon BY 0 • — AO <br />llnotrigetico !miner:Ilan BY AlW7A11 " <br />....--7 r <br />a, ,/ ,ii,,,,, Commerrttr <br />APPLICATION FOR WELL/PUMP PERM' <br />SA )AQUIN COUNTY PUBLIC HEALTH SE .CES <br />ENVIRONMENTAL HEALTH DIVISION ' <br />304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br />(209) 468-3420 <br />NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />APPLICATION IS HERE BY MADE TO THE SAN <br /> (Complete In Trinkets) <br />JOAQUIN COUNTY DEVELOPMENT TITLE, CHA <br />PARCEL SIZE/APNS <br />STAI;N/C- c 7-4(.24( ADDRESS 53C FAS f Ma koVi 1-; it,PtIONE 2cJ 9 /99 t; <br />CONTRACTOR Ac‘vpihi,e3 C. PA .ev)ii), few • ADDRESS ?a C.;‘) N. kik' /.50 kA-1 (o9ct 2 ?PHONE Z1.5 4 L. .7/ et) tc; t C)52L-. <br /> ADDRESS tics <br />/-f tz\'' <br />rrtrut.in <br />JUN 04 1998 <br />NVIHONMENTAL HEALTH <br />PERMIT / SERVICEs <br />JOB ADDRESS/OR APNI/ <br />OWNER'S NAME <br />AOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITh SAN <br />-e-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. r <br />51 5 IN ElyYnt51 Loop e 5 crry 2 -i ic -C-Z <br />SUB CONTRACTOR <br />PHONES <br />TYPE OF WELL/PUMP: <br />(TYPE OF PUMP) <br />0 DESTRUCTION. <br />INTENDED USE <br />NEW WELL <br />INSTALLATION <br />0 Now 0 Revolt <br />TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br />OTHER <br />VAPOR EXTRACTION WELL It <br />FIRST WATER LEVEL IQ <br />SOIL BORING 5 <br />INDUSTRIAL <br />0 DOMESTIC/PRIVATE <br />PUBLIC/MUNICIPAL 0 DRIVEN <br />IRRIGATION/AG 0 OTHER <br />XMONITORING <br />APPROX. DEPTH 2LI -c‘ _ <br />PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY <br />DIA. OF WELL EXCAVATION 5 <br />TYPE OF CASINO/STEEL/PVC Pv <br />DEPTH OF GROUT SEAL I I <br />GROUT SEAL INSTALLED BY 7/ r/ <br />0 OPEN BOTTOM <br />GRAVEL PACK/817E4 1:-.; <br />C5se- <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE VVORK 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: 1 CERTIFY THAT IN THE PERFORMANCE OF THE 1NOPK FOR WHICH <br />THIS prnp,AIT IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S tnnoto OR SUB-CONTRACTING SIGNATURE CERTIFIES <br />THE FOILOVVING: " I CERTIFY THAT IN THE PERFORMANCE OF THE VVORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CALIFORNIA." HE APPUCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 1204141S-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />file r.1 X tIncitk (9. e?/-41 Title <br />4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM on PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />S. LOCATION OF VVELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />P &.-10(). <br />PLOT PLAN (Dow to Seeks) Soots • to <br />I. NAMES or 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 />c7, <br />)'41' <br />C-> <br />ACCOUNTING ONLY: AIDS FAG/ <br />_ <br />PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECEIVED BY DATE FERMI /SERVICE REQUEST NUMBER INVOICE <br />3 co I cr , co :- , 0 <br />ii c V° L / ? / '' o-(' D <br />c S R\ o o \ S 5 6 <br />Pub. Health Serv. Enviro. 173 (1/97)