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SOIL BORING <br />0 <br />GeCT(nbe 3) <br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br />TYPE OF YVELIJPUMP: 0 NEW WELL <br />0 INSTALLATION <br />0 Now 0 Repel, <br />(TYPE OF PUMPI <br />0 DESTRUCTION: <br />MONTTORING WELL <br />0 CROSS-CONNECT REPAIR <br />DEPTH PUMP SET FT. <br />OUT-OF-SERVICE WELL 0 GEOPHYSICAL YVELL I <br />OTHER <br />VAPOR EXTRACTION WELL I <br />FIRST WATER LEVEL <br />INDUSTRIAL 0 OPEN eorrom DIA. OF WELL EXCAVATION <br />DOMESTIC/PRIVATE 0 GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC <br />PUBLIC/MUNICIPAL 0 DRIVEN DEPTH OF GROUT SEAL <br />IRRIGATION/AG 0 OTHER GROUT SEAL INSTALLED BY <br />MONITORING GROUT SEAL PUMPED. El Yea <br />APPROX. DEPTH IC C LOCKING CHESTER BOX/STOVE PIPE <br />PROPOSED CONSTRUCTION/DRILUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br />ON. CONCRETE PEDESTAL BY DRILLER: D V.. 0 No <br />A ) <br />DIA. OF CONDUCTOR CASINO <br />DIA. OF WELL CASING <br />SPECIFICATION <br />GROUT BRAND NAME <br />CI REPLACEMENT WELL <br />WELL SYSTEM REPAIR <br />H.P. <br />Stoned X Tltle Date <br />PLOT PLAN (Dreve to SoeteI Scale <br />NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. <br />OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. <br />••• run sicaJoartnAcr, rss 11.111.21 1110.11, GT.,. etc A. V 001,24/1 • GM, IDOCIPIll OCR <br />4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />.1 I on •TIkINIII nr wet I II IANITIMILl S • NM I IA /NC INI1AC 111.6.1111.1-trli CICTV <br />' to <br />/-9-9 bfV <br />Date <br />DEPARTMENT USE ONLY <br />ApplIcetlen Accepted By <br />Grote InepoctIon By T'urnp InspectIon By <br />Doetroctlen InepectIon <br />Comment.: <br />eCieyt &re ifir "tic I" <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 />ROM-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Compkto ho Tripliests) <br />APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />JOAOU1N COUNTY DEVELOPMENT TITLE, CHAPTER S-Ill 5.3 AND THE STANDARDS OF RAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR AM/lfi 3 • ) CITY c'---IC d ikir, PARCEL SIZE/AM/ <br />OWNER'S NAME i.e.k1 C-C ?(10(1.1.161-3 (--1C Clelpally ADDRESS P.O. 'ErA 66clei Wir)19'64" PHONES <br />Cet!)NTRACTOR G2 ,,,„6414,d .011p AtamEmei ..),Itrvil.Sc2 (....T9k4 <br />a6/10.111 CONTRACTOI. AD <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS AM/CATION 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 WO FS( FOR WHICH <br />THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORMA. CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: ' I CERTIFY THAT IN THE RERFORMANCE OF THE WOFEC FOR WHICH THIS PERMIT 19 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPDERATION LAWS OF <br />CALIFORNIA.' TELE APPLICANT ML/ST CALL44 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12001 4911-71423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />ACCOUNTING ONLY: AIDS FACE <br />mir <br />PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASTE RE EIVED BY DATE PEEWIT/SERVICE REQUEST NUMBER INVOICE <br />, <br />P , <br />Pub Health Serv. Enviro. 173 (1/97) <br />ez.ee <br />ORIGINAL <br />UCK <br />iJu▪ rr PHONE I <br />rop,C(4). .C.5cY -.311-7)