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CONSTRUCTION SPECIFICATIONS <br />DIA. OF WELL EXCAVATION <br />TYPE OF CASING/STEEUPVC <br />DEPTH OF GROUT SEAL • <br />GROUT SEAL INSTALLED BY <br />GROUT SEAL PUMPED: El Yee 0 No <br />LOCKING CHESTER BOX/STOVE PIPE <br />AIR ROTARY AUGER <br />DIA. OF CONDUCTOR CASING <br />DIA. OF WELL CASINO <br />SPECIFICATION <br />CONCRETE PEDESTAL BY DRILLER: 0Y.. 0 No <br />CABLE <br /> <br />OTHER <br />GROUT BRAND NAME rorl 111(4 (IsA 44tif <br />A <br />0 <br />0 <br />IT <br />S <br />INTENDED USE <br />INDUSTRIAL <br />DOMESTIC/PRIVATE <br />PUBLIC/MUNICIPAL <br />IRRIGATION/AG <br />TYPE OF WELL <br />0 OPEN Borroke <br />CI GRAVEL PACK/SIZE <br />DRIVEN <br />0 OTHER <br />MONITORING <br />APPROX. DEPTH <br /> wbc <br />PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY <br />DEPARTMENT USE ONLY <br />Dote // 2 7 /7 Porno Impaction By <br />,ept <br />7 ,c <br />- <br />o.,.. 1 2/(1/ _ , <br /> Area ApplIcetlers Accepted By <br />Grout Inspection By /l•cill</ <br />Co.nn,enI.r 7 FIL-1 4/1,te,..Z <br />Doetroctlen Inspection 11414 <br />c `c <br />(Complete he TrIplkats1 7_ <br />7e) (17",r:Piy <br />APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOFK 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/011 APNE 3 CI 7 E Ij JLI w ay 4 1) crry 1.—ocg-eforct <br />ADDRESS 5"5. W . 3 1.14 5 Z. ,Ua nrercl PHONE E 5- 3 33q OWNER'S NAME GI I '! vcit-ia P1 M 4 <br />ADDRESS 4 005 Pi• Wel y pc, 6 SO 2-2- 7 PHONE 6 7 -006 CONTRACTOR Ativdif ( G.cs viebel AVIA fcl I ITN ( <br />SUB CONTRACTOR ADDRESS UCE PHONE I <br />TYPE OF WELL/PUMP: 0 NEW WELL 0 REPLACEMENT WELL 0 MONITORING WELL 0 0 OTHER <br />D INSTALLATION CI WELL SYSTEM REPAIR D CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELL 1 J <br />0 New 0 RepeIr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0 <br />(TYPE OF PUMP) <br />tsiDESTRUCTION: <br />0 OUT-OF-SERVICE WELL <br />t 7 -; wells Ptht7 "irl" <br />0 GEOPHYSICAL WELL E <br />U515 <br />0 SOIL BORING <br />..0 <br />—J <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE VVORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND <br />REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: CERTIFY THAT IN THE PERFORMANCE OF THE WON( FOR WHICH cc, <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 IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CAUFORNIA.- THE APPUCANT MUST CALI, 24 HOURS IN ADVANCE FOR AU. MEOWED INSPECTIONS AT 120111411111-.1423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />13118.I1 x )4PVAT.1 /144--)051121/1"1 Title 5* le V 5 1f f' (7.01011NsT Di. ct -1 5 -7 <br />PLOT PLAN (Drew to Sordel Scale <br />NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. <br />OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. <br />DIMENSIONED OUTUNES AND LOCATION OF ALL EXISTING AND PROPOSED <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. <br />te <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 />... <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-REFUNDARLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />PARCEL SIZEJAPNE <br />ACCOUNTING ONLY: AIDE FACE <br />I) ,.. 1... I-- <br />PE CODES FEE INFO AMOUNT REMITTED CH114,1/CASII RECEIVED BY DATE <br />. <br />PERNIU/SERVICE REQUEST NUMMI INVOICE <br />„'...:•::.(:; 7172, <br />er 1)t.) t 1 /7 Z V if 0/ fr,---''-) S <br />!-------7----------- ' <br />P\ C) \ VI g 2 5 <br />Pub Health Serv. - Enviro. 173 (1/97)