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CONSTRUCTION SPECIFICATIONS <br />DIA. OF WELL EXCAVATION <br />TYPE OF CASING/STEELIF'VC PV C.' <br />DIA. OF CONDUCTOR CASINO <br />DIA. OF WELL CASINO 2 - ince <br />Area Date <br />Date <br />t—Pump Inspection By <br /> <br />Applle.tIon Accepted By <br />Grout Intpeptilon By <br /> <br />Demtrloctlen tr.pocllyA fly <br />DEPART ENT USE ONLY <br />APPLICATION FOR WELL/PUMP PERIl <br />Si -)AQUIN COUNTY PUBLIC HEALTH SL ICES <br />ENVIRONMENTAL HEALTH DIVISION <br />304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br />(209) 468-3420 <br />NON•REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete In Triplicate) <br />APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. TIIIS APPLICATION IS MADE IN COMPLIANCE W1111 SAN <br />JOAOUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1 11 5.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES. ENVIRONMENTAL HEALTH DIVISION. <br />CITY S4 -0()(lon PARCEL SIZE/APN* <br />OWNER'S NAME Nk As Dal 0 Sc 14-T 7 ADDRESS Pri /. C . V3/ slow, n gael mow t?ciq 1iY 66-7 <br />CONTRACTOR AkANon awl,'" (4C...5 ADDRESS 1 tV ii615 01% ue, 45'1,5c Z27 moNt <br />SUB CONTRACTOR <br />JOB ADDRESS/OR APN/ CASTi <br />Srock3,n , Lit q5t or <br /> ADDRESS UCI PHONE <br />NEW WELL <br />'El INSTALLATION <br />0 New 0 Repair <br />TYPE OF WELL/PUMP: <br />(TYPE OF PUMPI <br />0 DESTRUCTION: <br />REPLACEMENT WELL <br />MONITORING WELL I i? <br />13 WELL SYSTEM REPAIR <br /> 0 CROSS-CONNECT REPAIR <br />H.P. DEPTH PUMP SET FT. <br />OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL S <br />OTHER <br />1:1 VAPOR EXTRACTION WELL I <br />FIRST WATER LEVEL r;:°.;Z 303 FRI <br />SOIL BORING e <br />INTENDED USE TYPE OF WELL <br />0 INDUSTRIAL 0 OPEN BOTTOM <br />. 0 DOMESTIC/PRIVATE 0 GRAVEL PACK/SIZE. <br />El PUBLIC/MUNICIPAL 0 DRIVEN <br />IRRIGATION/AO 0 OTHER <br />in MONITORING <br />APPROX. DEPTH VC 'RE ' <br />PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY <br />DEPTH OF GROUT SEAL I 1-...F.. il 4...e 2.14 .. ) j..., ..., SPECIFICATION -410 V ik y0 <br />GROUT SEAL INSTALLED BY '7)'h 4 /Pe GROUT BRAND NAME CR 71-0 /-49 <br />GROUT SEAL PUMPED: Wu, D No CONCRETE PEDESTAL BY DRILLER: Yor El No <br />LOCKING CHESTER BOX/STOVE PIPE <br /> 1441 13wx <br /> AIR ROTARY AUGER <br />CABLE <br /> <br />OTHER <br />A <br />I HERESY 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 JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: *I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <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 />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." TILE APPUCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REWIRED INSPECTIONS AT 12001 40114423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Signed X Title fl e 1(351 si Date <br />PLOT PLAN (Drew to Scale) Scale • to <br />NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. <br />OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. <br />T. DIMENSIONED OUTLINFS AND LOCATION OF ALL EXISTING AND PROPOSED <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. <br />4. 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 />ACCOUNTING ONLY: AID,/ FAC 0 <br />PE CODES FEE INFO AMOUNT RENIITTED CHECKS/CASH RECEIVED BY DATE PERIVIITMERVICE REQUEST NUMBER INVOICE <br />, ) , y9 c C,;1-- 3 -z" h/5079/ ()//,'/ <br />Pub. Health Health Serv. - Enviro. 173 (1/97)