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TYPE OF WELL/PUMP: 0 NEW WELL <br />El INSTALLATION <br />0 Now 0 Retook <br />(TYPE OF PUMPI <br />MONITORING WELL 5 0 OTHER El REPLACEMENT WELL <br />0 WELL SYSTEM REPAIR <br />H.P. <br />0 OUT-OF-SERVICE WELL <br />CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELL <br />DEPTH PUMP SET FT. FIRST WATER LEVEL <br />GEOPHYSICAL WELL IX SOIL BORING <br />0 DESTRUCTION: <br />DIA. OF CONDUCTOR CASING <br />DIA. OF WELL CASINO <br />SPECIFICATION <br />GROUT BRAND NAME <br />CONCRETE PEDESTAL BY DRILLER: 0 Yoe El No <br />TYPE OF WELL <br />0 OPEN BOTTOM <br />0 GRAVEL PACK/SIZE <br />0 DRIVEN <br />0 OTHER <br />INTENDED USE <br />INDUSTRIAL <br />DOMESTIC/PRIVATE <br />PUBUC/MUNICIPAL <br />El IRRIGATION/AG <br />MONITORING <br />APPROX. DEPTH <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 />GROUT SEAL PUMPED: 0 Yea 0 No <br />LOCKING CHESTER BOX/STOVE PIPE <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 />AppllootIon AerooPlod BY <br />Grout Iropectko, By <br />Do.tomilon loopoetIon By <br />C ononoto.: <br /> ..=m=nnikohme, <br />DEPARTMENT USE ONLY <br />) Pump In.poetIon By <br />Ctf- Dote /C6.--- Arai <br />Dote <br />Dm. <br />APPLICATION FOR WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <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 JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />JOAOUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR AM/ Ii q to tAJ t- In tit ;•(._ crTY EI.4040./4_P A <br />OWNER'S NAME <br /> qILJLk s4cp 14 Ai- <br />CONTRACTOR <br /> p 4w cl , <br />SUB CONTRACTOR Pe tc. i ten. 6—) '5"4-1ph.. 2AI t, <br />ADDRESS 417 pr. /-r o.,/ <br />PARCEL WC? 2 I7- 240-1/ <br />c/o <br />PHONES asez kpit t'. 4a_..,, piti-t!.-1 5*E• 3.4 92S ADDRESS 10 le 4#14„,,,ptcaj 90444 LICE PHONES — sa5s,s <br />4 7Lpolt_sr: <br />ADDRESS So4dj M. + Cs _14 uci 387 PHONE S <br />'IV D I <br />PROPOSED CONSTRUCTION/DRILUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AN131,, ) <br />REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER on UCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WON( 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 ,,.,,/r/' <br />THE FOLLOWING: ' I CERTIFY THAT IN THE PERFORMANCE OF THE WORE FOR WHICH THIS PERMIT 18 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF / <br />CAUFORN1A.' TjIE APPLICANT MUST CALL 24 URS IN ADVANCE FOR ALL REQUIRED INSPWRO/811 AZ (2281 4811,.423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />R.6 ..l°' trifY <br /> <br /> LP <br />— 61.4.4.7 k Title <br />. pev.C.C.,- &ce.Loy Ser" stoned X <br /> <br />PLOT PLAN (Drew to Boole) Scale to <br />I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. <br />2. OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. <br />3, DIMENSIONED OUTUNF.8 AND LOCATION OF ALL EXISTING AND PROPOSED <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. <br />Date ?.-18 '98 <br />(<-) <br />A- 44c- fr/A-p. S <br />ACCOUNTING ONLY: AIDS FACE <br />PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECEIVED BY DATE PERIVIIT/SERVICE REQUEST NUFABEFI INVOICE <br />3 co i iq9.00 2-11-z_ tJ1 'it is' <br /> <br />Pub Health Servs - Enviro. 173 (1/97)