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CONSTRUCTION SPECIFICATIONS s‘ <br />DIA. OF WELL EXCAVATION 5 c DIA. OF CONDUCTOR CASING ,ki A <br />DEPTH OF GROUT SEAL 35 <br />TYPE OF CASING/STEEL/PVC <br /> <br />%A <br />GROUT SEAL INSTALLED BY fli`LOPA ,L., X e- <br />GROUT SEAL PUMPED: s?. 0 No <br />LOCKING CHESTER SOX/STOVE PIPE <br />DIA. OF WELL CASING Ai ,A <br />SPECIFICATION Ai!) <br />GROUT BRAND NAME )-.1.4,-kO.11f4--- <br />CONCRETE PEDESTAL BY DRILLER: 0 Yoe NINo <br />AIR ROTARY AUGER CABLE D r OTHER <br />Dela <br />Pump Inspection By D•to <br />DEPARTMENT USE ONLY <br />Dale fee <br />Cornmegor <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 TripHeats, <br />APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />JOAOUIN COUNTY DEVELOPMENT TITLE. CHAPTER 9-1 1 1 5.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR APNI I 3 -Z Ajov-A-An k %.1-\ \ %rt. CITY --. PARCEL SIZE/APNO ()° <br />OWNER'S NAME Et.', v‘. '‘P S .6,‘,N:1-1ti-ADDRE139 19 3 !\..) L PHONES <br />CONTRACTOR A v \-7) 'S &A:L.- V=3 (. v1/4-A - ADDRESS 14-;\ 11'6 UCA PHONE # - <br />SUB CONTRACTOR ADDRESS Po 6c,,y, 5 , tic. 1--2.c. 'CIA PHONE /717.'7- 131#4.. 2-3 <br />TYPE OF WELL/PUMP: 0 NEW WELL <br />0 INSTALLATION <br />0 Now 0 Repair <br />(TYPE OF PI/MPI <br />0 DESTRUCTION: <br />REPLACEMENT WELL <br />WELL SYSTEM REPAIR <br />II.P, <br />OUT-OF-SERVICE WELL <br />MONITORING WELL / <br />El CROSS-CONNECT REPAIR <br />DEPTH PUMP SET FT. <br />GEOPHYSICAL WELL <br />OTHER <br />VAPOR EXTRACTION WELLS <br />FIRST WATER LEVEL <br />WSOIL BODING CI <br />INTENDED USE <br />INDUSTRIAL <br />DOMESTIC/PRIVATE <br />PUBLIC/MUNICIPAL <br />IRRIGATION/AG <br />MONITORING <br />APPROX. DEPTH <br />TYPE OF WELL <br />o OPEN BOTTOM <br />0 GRAVEL PACK/SIZE <br />0 DRIVEN <br />0 OTHER <br />PROPOSED CONSTRUCTION/DRILUNO METHOD: MUD ROTARY <br />(.<\ I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW 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 UCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: •1 CERTIFY THAT IN THE PERFORMANCE OF THE VVOW 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 VVORK FOR WHICH THIS PERMIT IS ISSUED. I SHALL EMPLOY PERSONS SUBJECT TO WORIOIAAN'S COMPENSATION LAWS OF <br />CAIJFORNIA.' THE APPUCANT MUST CALL 24 HOURS IN ADVANCE FOR All REQUIRED INSPECTIONS AT 12051 4011-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Signed X Title BA CtAA.4.--11 )111.Cr- Dots <br />PLOT PLAN Prow to Scale' S.I. <br />I. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING 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 />LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM on PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />ACCOUNTING ONLY: AIDS FACE <br />PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH C ED NY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />1,....,- ,,,,,, <br />-3L1- r <br />/ <br />Pub Health Serv. - Enviro. 173 (1/97)