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--41443-efIMPRACTOR ADDRESS UCI PHONE <br />S SOIL BORING <br />4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />B. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />NOT PLAN (Draw to Soele) Scale to <br />NAMES or STREETS OR ROADS NEAREST TO OR 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 />Application Accooted By Dote <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 />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete In Trip!kale) <br />COUNTY FOR A PERMIT TO CONSTRUCT AND/011 INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />owtrEn•aMME C ADDRESS JIPX)y <br />PHONE J <br />CtrA-fPo'LLSC14-"-- CON. <br />Pi) eiC <br />ADDRESS 7'1 PHONE <br />MILLI PUN <br />APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN <br />JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 8-1 <br />JOB ADDRESS/OR APT!, Si4 61 " F I <br />CITY r ) PARCEL SIZE/APNS <br />tit 0 MONITORING WELL I — <br />CROSS-CONNECT REPAIR <br />DEPTH PUMP SET FT. <br />GEOPHYSICAL WELL <br />,2%( I."C <br />PROPOSED CONSTRUCTION/DRILUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br />INTENDED USE <br />INDUSTRIAL <br />Cl DOMESTIC/PRIVATE <br />Cl PUBLIC/MUNICIPAL <br />IRRIGATION/AG <br />Ca MONITORING <br />APPROX. DEPTH 7_ LOCKING CHESTER BOX/STOVE PIPE <br />GROUT SEAL INSTALLED BY <br />t PG <br />TYPE OF WELL <br />0 OPEN BOTTOM <br />0 GRAVEL PACK/SIZE <br />0 DRIVEN <br />0 OTHER <br />DIA. OF WELL EXCAVATION <br />TYPE OF CASING/STEEUPVC <br />DEPTH OF GROUT SEAL <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF CONDUCTOR CASINO <br />7 " DIA. OF WELL CASINO <br />SPECIFICATION <br />GROUT BRAND NAME <br />GROUT SEAL PUMPED! 0 Yes Igt No <br />A <br />0 <br />CONCRETE PEDESTAL BY DRILLER: 0 Y.. No <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATION 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: 1 CERTIFY THAT IN THE PERFORMANCE OF TIIE VVORK FOR WHICH <br />THIS 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 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.' TPPUCAN R4UST CALL 24 HOURS IN ADVANCE FOR AU. REQUIRED INSPECTIONS AT I20411 4664422. COMPLETE DRAWING AT LOWER AREA PROVIDED. 7 <br />, ..,..1 Title Oslo Slprusel X <br />SAi. J0.40. IN COJ4TY <br />PUBOC14EALTHI,';;ERVICES <br />ENV1ROWE14TAL HEALTH DIMON <br />DEPARTMENT USE ONLY <br />• Pub. Health Health Serv. - Enviro. 173 (1/97) <br />Onetroetion Impaction By <br />Comment... <br />C <br />Date <br />5- r o (_ke r\F- relYYLC 00. <br />—5 VC-12 4A-SCA— CP <br />-,,,r—Ae\.6J, 5-111161 -1==-Kk- <br />Y rf <br />ACCOUNTING ONLY: AIDS <br />i <br />FACt 1 S , (_(_,LVY-le -4e---- <br />11''' .4 e ..S. <br />. • qy. ---.. <br />- ' C 'I O-y\ — <br />PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />1 1.2=(?) 1,2-11 cy? ID 1--11 61 <br />cloo- (.170 <br />/ <br />- „-- Sc\00 o nci- • <br />REPLACEMENT WELL <br />WELL SYSTEM REPAIR <br />H.P. <br />OUT-OF-SERVICE WELL <br />'.•fc:`). ) <br />OTHER <br />VAPOR EXTRACTION WELL S <br />FIRST WATER LEVEL <br />Pump Inspection By <br />TYPE OF WELUPLIMP: 0 NEW WELL <br />0 INSTALLATION <br />0 New 0 1109.1! <br />(TYPE OF PUMP) <br />DESTRUCTION: <br /> Rer.titit. <br />Grout Inaproction By <br />Area <br />Oats