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Et SOIL BORING (TYPE OF PUMP) 0 OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL I t<- PLOT PLAN 03.sw to Sootel Boole I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. a,ca- Pomp Inspection By Application Aocepted By Grout Impection By /--z-Oils - DEPARTMENT USE ONLY Atoo 061V Dots Delo 2. 0 2ted/ DoottootIon Impectloo sr Coontrootv 19/4.1Se, .1 •••• APPLICATION FOR WELL/PUMP PERMIT 5 1 — 2— SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. T/119 APPLICATION IS MADE IN COMPLIANCE WTTII SAN JOAQUIN COUNTY DEVELOPMENT TITLE. CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR API./ _ PARCEL SIZEJAPN/ "7._- OWNER'S NAME571bAie 64.05. /41.1W irtizotachil. 04)t•ADORESS->ii-, "IT(. 4s 2 PHONES C.- iekshrivol CONTRACTOR 1, trt ..: • - ADDRESS F r),c,, Aa r..MA SS, +t (.0 UCE 4•C. 3 /4PHONE I La) Tiii-qics- , (A '1'-i -1'S , 1- 4 '1 PHONE F 7-1• 4 SUS CONTRACTOR 'LC,' lb< ADDRESS -3 7 uct TYPE OF WELL/PUMP. 0 NEW WELL 0 REPLACEMENT WELL Et MONITORING WELL I 14 A 0 OTHER INSTALLATION 0 WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELL 0 Now 0 Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0 0 DESTRUCTION. TYPE OF WELL CONSTRUCTION SPECIFICATIONS A 0 OPEN BOTTOM DIA. OF WELL EXCAVATION '!. DIA. OF CONDUCTOR CASING i.‘.21- . • <" . D O GRAVEL PACK/SIZE V"‘".......A 3 TYPE OF CASING/ST EEUPVC e .4 4.-• 56.4. DIA. OF WELL CASING 7. ' 17 0 onivEN DEPTH OF GROUT SEAL iflOV SPECIFICATION ." ..• ,-- , .... . -4 L R 0 OTHER GROUT SEAL INSTALLED BY " -,..". '-r 5- V : (A. GROUT BRAND NAME 1-',.....- v I, ...,,t' J ir E GROUT SEAL PUMPED: El Yes ON. CONCRETE PEDESTAL BY DRILLER: 0 Yoo 0 No s LOCKING CHESTER BOX/STOVE PIPE 9 L.51 PROPOSED CONSTRUCTIONTDRILUNG METHOD: MUD ROTARY AIR ROTARY AUGER /••••••- CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES. STATE LAWS, AND RULES AND G---- REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR UCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE VVOPIK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA. COS/TRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: • 1 CERTIFY THAT IN THE PERFORMANCE OF THE WOFV( FOR WHICH THIS PERMIT 18 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.- THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR AU, REQUIRED INSPECTIONS AT 12011) 41111-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. L..-4"iie-ta_t_ Till. .‘...-Yic....4.' -4- (")'!...i.".• ..-03%.JI.T Dote i 1 i.-/ 't ,3 I .5 (1/4) \tWJ IL Or/JI. 3 W'altri 'PRA (lec ,• OR Signed X LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED EXPANSION OF SEWAGE DISPOSAL SYSTEMS. S. LOCATION OF WELLS vvrnow RADIUS OF ONE HUNDRED FIFTY FT. ON THE PROPERTY OR ADJOINING PROPERTY. t ACCOUNTING ONLY: AIDS FACN S'Rtf) 1 # PE CODES FEE INFO AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT/SEFIVICEREO INVOICE 0 41.4iLd' Alf - 41, re 147i i Mili/M, -E._.a;W'A 0/ 0 Pub Health Serv. Enviro. 173 (1/97) to INTENDED USE INDUSTRIAL DOMESTIC/PRIVATE PUBLIC/MUNICIPAL IRRIGATION/AG MONITORING APPROX. DEPTH 'SW/ C' cr--