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INTENDED USE <br />INDUSTRIAL <br />0 <br />o <br />DOMESTIC/PRIVATE <br />o PUBUC/MUNICIPAL <br />IRRICIATION/AG <br />ra MONITORING <br />APPROX. DEPTH <br />TYPE OF WEU. <br />OPEN BOTTOM <br />14 GRAVEL PACK/SIZE <br />0 DRIVEN <br />0 OTHER <br />6 cs <br />* 3 <br />PROPOSED CONSTRUCTION(DRILUNG METHOD: MUD ROTARY <br />Application Accepted er <br />Den) Pump InopeetIon By Grout Inepectletl By <br />Date V -z.) 3/ c V Al.. <br />tA /S,4 AAA/1/s.. <br />APPLICATION FOR WELL/PUMP PERMIT <br />SAN JOAQUIN COUNT( 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 JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR( DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE MTH SAN <br />JOAOUIN COUNTY DEVELOPMENT TITLE. CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />-4-QimiAisi+.414we-44-, 16.7 -3—CILDO cfry <br />OWNER'S NAME -F1117"1""j'ir-4444"1-64-/--84*41‘ ADORESE1 rio. 614 r,A LACC*11 <br />CONTRACTOR licivo 0(.4 L. et, rovi ovi.tda <br />SUB CONTRACTOR 501 1 EX ploodiGei <br />c <br />TYPE OF YVELUPUMP: <br />(TYPE OF PUMP) <br />0 DESTRUCTION: <br />NEW WELL <br />INSTALLATION <br />0 New 0 Repair <br />REPLACEMENT WELL <br />0 WELL SYSTEM REPAIR <br />H.P. <br />OUT-OF-SERVICE WELL <br />pt. MONITORING WELLS 0 OTHER <br />0 CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELL S <br />DEPTH PUMP SET FT. FIRST WATER LEVEL 0 <br />0 GEOPHYSICAL WELLS 0 SOIL BORING <br />JOB ADDRESS/OR AMR PARCEL 81ZEJAPNS <br />PHONE I/3 I JO I <br />ADDRESS 400 141, it.1W4y ucir 6•430;.)-7 rHows4t7-1066 <br />ADDRESS1134 Fraitrt4 ( R4.1 50e LICE P516'16 PHON 'Els". 365 •A)42, <br />CONSTRUCTION SPECIFICATIONS A <br />DIA. OF WELL EXCAVATION IS DIA. OF CONDUCTOR CASING ..... n <br />TYPE OF CASING/STEEL/PVC 2 " P v. (.._ DIA. OF WELL CASING , <br />; rr <br />0 <br />DEPTH OF GROUT SEAL . 4 0 ' SPECIFICATION 5-c ti . 4C) R <br />GROUT SEAL INSTALLED BY 11'4 14404 R GROUT BRAND NAME pt...1 ic Ali E <br />GROUT SEAL PUMPED: El Yee O N. CONCRETE PEDESTAL BY DRILLER: 0 Yee GIN., .5 <br />LOCKING CHESTER BOX/STOVE PIPE s <br /> AIR ROTARY AUGER A CABLE OTHER <br />I HEREBY CERTIFY THAT) 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 JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: I CERTIFY THAT IN THE PERFORMANCE OF THE WON( FOR WHICH <br />THIS PERMIT 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 PI THE PERFORMANCE OF THE WON( FOR WHICH THIS PERMIT 18 ISSUED. I SHALL EMPLOY PERSONS SUBJECT TO WORIOAAWS COMPENSATION LAWS OF <br />CAUFORNIA. THE APPUCANT MUST CALL 24 HOURS IN ADVANCE FOR All. REQUIRED INSPECTIONS AT 120•I 4115-3F423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />SignedX ,A14144e-- 11/AA-24144- Title 511. 'fa Dot. <br />PLOT PLAN (Maw to %Pa) Scale • to <br />NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />DIMENSIONED °MUNE@ AND LOCATION OF ALL EXISTING AND PROPOSED S. 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 />.. ..... ••i <br />... <br />................ <br />DEPARTMENT USE ONLY <br />Onetneetion trwreetIon By <br /> Date <br />Commeritc <br />ACCOUNTING ONLY: AIDS <br /> FACE <br />PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECEIVED SY DATE PERMIT/SERVICE REQUEST NUMBEF1 INVOICE <br />4 sq, it isetoo 1 b--Ict 14 I -x-13/16-56)0 I -3- --4-3_1-1 <br />Pub Health Serv. - Enviro. 173 (1/97)