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JOB ADDRESS/OR APN/7 <br />OWNER'S NAME <br />CONTRACTOR <br />SUB CONTRACTOR 1 <br />- <br />y eqz--ce-1 <br />- <br />TYPE OF WELIJPLIMP: O NEW WELL <br /> El REPLACEMENT WELL <br />INSTALLATION <br /> ID WELL SYSTEM REPAIR <br />0 New 0 Repair <br />HYPE OF PUMP) <br />TYPE OF WELL A <br />5 <br />01A. OF WELL CASING <br />SPECIFICATION <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF WELL EXCAVATION 8" <br />TYPE OF CASING/STEE <br />DEPTH OF GROUT SEAL <br />GROUT SEAL INSTALLED BY <br />DIA. or CONDUCTOR CASING <br />Z),r-L <br />CABLE PROPOSED CONSTRUCTION/DRILUNG METHOD: MUD ROTARY <br />GROUT SEAL PUMPED: CI Y CI No <br />LOCKING CHE TER X/STOVE PIPE <br /> AIR ROTARY AUGERV <br />INTENDED USE <br />INDUSTRIAL p 07N BOTTOM <br />DOMESTIC/PRIVATE WRAVEL PACK/SIZ <br />El PUBLIC/MUNICIPAL 0 DRIVEN <br />IRRIGATION/AO 0 OTHER <br />NrMONITORING <br />APPROX. DEPTH <br />/7, (i <br />GROUT BRAND NAME <br />CONCRETE PEDESTAL BY DRILLER: 0 Yes 0 No <br />OTHER <br />Application Act:footed By <br />Grout Impection By <br />OnstrtctIon ImpectIon <br />Conunenitc <br />DEPARTMENT USE ONLY <br />Dot. <br />ZVff Date fPun Impaction By <br /> Dole <br />. APPLICATION FOR WELL/PUMP PERM"' <br />SP 1AOUIN 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 />(Complete In Triplicate) <br />APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />UIN COUNTY PUBLIC HE LTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />PARCEL SIZE/APFIS (211 <br />-7 <br />Aar — <br />ADDRESS 44;CS- talS13.) P7 mow # '477 /etec..) <br />ArmcksV/3 uc, ,<,t)„q9 s t y <br />—1111.0=ear,ist <br />CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELLS <br />DEPTH PUMP SET FT. FIRST WATER LEVEL <br />0 OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL if <br /> 0 SOIL BORING <br />0 DESTRUCTION, <br />DO do <br />JUL 1 3 199111 <br />JOAOUIN COUNTY DEVELOPMENT TITLE. CHAPTE .3 AND THE STANDARDS OF SAN JO' <br /> &-e7t---614 <br />MONITORING WELLS 0 OTHER <br />t-4'25 A) iY.'a,AA-7-e-i 7LIV <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE VVOW 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 WOW FOR WHICH <br />THIS rEREArr IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA. CONTRACTORS HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: " 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.-1 CANT MUST C 4 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 120111 40S-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Monad X Title • Dote --9"? <br />PLOT PLAN (Draw to Boole) Seale <br />I. NAMES OF STREETS OR ROADS NEAREST TO on 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 />1. <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 on ADJOINING PROPERTY. <br />s. <br />• <br />ACCOUNTING ONLY: AIDS Eike, <br />PE CODES FEE INFO AMOUNT REMITTED ef ...b. CHECKS/CASH RECEIV D By , , i DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />3 .---(. Z335- <br />. <br />/ V 1 3/1 0 I t 25-6 r1 <br /> <br />Pub. Health Serv. - Enviro. 173 (1/97)