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TYPE OF WELL/PUMP: <br />(TYPE OF PUMPI <br />NEW WELL <br />INSTALLATION <br />0 New 0 Repair <br />REPLACEMENT WELL <br />WELL SYSTEM REPAIR <br />H.P. <br />MONITORING WELLS <br />CROSS-CONNECT REPAIR <br />DEPTH PUMP SET FT. <br />OUT-OF-SERVICE WELL GEOPHYSICAL WELL <br />LICE PHONE <br />0 OTHER <br />VAPOR EXTRACTION WELL S J <br />TYPE OF WELL <br />o OPEN BOTTOM <br />ril GRAVEL PACK/SIZE <br />0 DRIVEN <br />0 OTHER <br />CONSTRUCTION SPECIFICATIONS A <br />LOCKING CHESTER BOX/STOVE PIPE <br />DIA. OF WELL EXCAVATION <br />TYPE OF CASING/STEEL/PVC <br />DEPTH OF GROUT SEAL <br />a Ng <br />v <br />Ci <br />GROUT SEAL INSTALLED BY jA91k.: <br />GROUT SEAL PUMPED: CI Yee El No <br />DIA. OF CONDUCTOR CASING <br /> fr <br />DIA. OF WELL CASINO <br />SPECIFICATION <br />GROUT BRAND NAME <br />CONCRETE PEDESTAL BY DRILLER: 0 Yee 0 <br />DEPARTMENT USE ONLY <br />Application Acceptor! By <br />:maim u t <br />9 0,5"—V6--- <br />rNi <br />JOAQUIN COUNTY DEV L T igtan 9-1115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES. ENVIRONMENTAL HEALTH DIVISION. <br />APPLICATION IS HERE flarZ TgE AQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/011 INSTALL THE WON< DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />Cu-sr rn, JOB ADDRESS/OR APNI.g.Ailf1707,-,-,00N <br />L4 v <br /> <br />ADDRESS 114?-3 V• • 1'1°1 4/6C 5— p„o7Ef -s61-- Z 2. 2Z- <br />SUB CONTRACTOR aromas C_ <br />FIRST WATER LEVEL <br />SOIL BORING <br />10 DESTRUCTION: <br />INTENDED USE <br />INDUSTRIAL <br />IX DOMESTIC/PRIVATE <br />PUBLIC/MUNICIPAL <br />IRRIGATION/AG <br />MONITORING <br />APPROX. DEPTH <br />PROPOSED eamearteeinereronaurre METHOD: MUD ROTARY AIR ROTARY AUGER IX ABLE <br />D <br />OTHER <br />I I-IE8EBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WON( 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 WORK FOR WHICH <br />TI118 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 />THE •LLOWING: 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 />CAll NIA.' Talls CANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12001 4111/-3423.,,COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Sip Title Et, tgP‘M Date 4Ls<ri Cfiqr <br />PLOT PLAN (Draw to &Wel Scale / t din Pr <br />1. N ES or STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />2 OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED <br />5. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br />PLICATION FOR WELL/PUMP PERMIT <br />SAN UIN COUNTY PUBLIC HEALTH SEM <br />tVIRONMENTAL 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 />OVVN NAMENVIR fittrirkfr( r <br />-S <br />fUrls <br />::ALIH SP <br />ShiS" cA. S.-v-02.4e .XYL, <br />ADDRESS <br />PARCEL SIZE/APNO <br />rAyi-evz-- ftec,4;A4lifi/ cid-",0N7P-5-o• ‘7y F274. <br />0 All ( "Ill( <br />(4;1/0 +b Ire <br />-tirC <br />cz\ <br />Date d- 7 Area 0 7_5-1 <br /> Date Pump Inspection By <br />0.41rtoetIon Inspection Ely ) AZIJ 21Y4,4 f/ (u <br />/-,/7 / <br />I () • a/ "14 'e4,,e -e/t 0.4;;e41 V 4- <br />4-0 e <br />ACCOUNTING ONLY: AIDS _........C1 6....,.....) Cr& ..,/ <br />-0(6 0 , 0 ) Ca/ fr-PI-'6:27 FACE .,01/(?, <br />PE CODES FEE INFO AMOUNT REMITTED <br />./..- <br />RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE LIECO/CASTI <br />3 5- OP—, .462-8----- /-0-0-' C O 6r/7/9er 0 / (07 a-- L, 31 7 v <br />Pub. Health Serv. - Enviro. 173 (1/97) <br />Grout Impaction By Data <br />Comment.: