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Title ,a'ai Der.e.r Date "2 Signed X <br />074-d Date 2/2,41. AT m <br />Dote Date Pump Inspection By <br />DEPARTMENT USE ONLY <br />Data r <br /> <br />Application Accepted By <br />Grout Inspection By <br /> <br />Destruction Inspection Y <br />Comments: r•ti ( 17\- tAi Cet- se c <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 />NOW REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete In TripIke's, <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 />JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR APPI* Val* Gr6-ert Rd criv . PARCIELS01Z6E/AIPN*Z5() <br />OWNERS NAME C b ADDRESS /5-3/ raw/ 4c. 5-et n /14a rf:a5 PHONE I/ (76.9) 471 - .1500 <br />yo 5-1 CONTRACTOR ./VG i a in olef'Se, :SO C. ADDRESS 2.7- //ra-Ikri 4/ <br />) 4 <br />°0/. UCI1 X6 70011 PHONE I 36.7- 3 7o/ <br />SUB CONTRACTOR UC// PHONE I/ ADDRESS <br />TYPE OF WELIJPUMP: 0 NEW WELL <br />0 INSTALLATION <br /> 0 New 0 Repair <br />REPLACEMENT WELL <br />WELL SYSTEM REPAIR <br />H.P. <br />MONITORING WELL * <br />CROSS-CONNECT REPAIR <br />DEPTH PUMP SET FT. <br />OTHER <br />VAPOR EXTRACTION WELL <br />FIRST WATER LEVEL <br />(TYPE OF PUMPI <br />0 OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL <br />XDESTRUCTION: Ov•6r 6-,7/ 4r,tct tici_te-inmie.- c-too? 7 -0. 1-o S'e,r-c.i-ce <br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br />0 INDUSTRIAL 0 OPEN BOTTOM DIA. OF WELL EXCAVATION es,. / 2 ( DIA. OF CONDUCTOR CASINO /2 <br />0 DOMESTIC/PRIVATE 0 GRAVEL PACK/SIZE TYPE OF CASINO/STEEL/PVC DIA. OF WELL CASING o <br />0 PUBLIC/MUNICIPAL 0 DRIVEN DEPTH OF GROUT SEAL r4-4.,- i).60,7%1 SPECIFICATION R <br />0 IRRIGATION/AO 0 OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME Vi•A—r,47() ..r 1-,2r E <br />e GROUT SEAL PUMPED: 0 Yee pi No(T44s wi ow") CONCRETE PEDESTAL BY DFULLER: 0 Y. ON. S 0 MONITORING <br />/./.."' APPROX. DEPTH "1. ,...,.... 2-0 LOCKING CHESTER BOX/STOVE PIPE $ <br />PROPOSED CONSTRUCTION/DRILUNG METHOD: MUD ROTARY AIR ROTARY AUGER X CABLE OTHER <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 LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: I CERTIFY THAT IN THE PERFORMANCE OF THE WORK 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 C FY THAT IN TN 11FORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CALIFORNIA.' T ANT MUST S HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 1200148S-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />SOIL Boma a <br />PLOT PLAN (Drew to Scale) Scale ' to <br />NAMES STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />OUTLINE OF THE PROPERTY. GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, <br />DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. ON THE PROPERTY on ADJOINING PROPERTY. <br /> <br />/MeV< //1)6 C. L <br />Z. o citizeW <br /> <br />To 1.205 ) <br /> <br />Grant Line Read <br /> <br />1e <br /> <br />. ... . ,,,,, .... <br /> <br />ACCOUNTING ONLY: AID* FACE <br />PE CODES FEE INFO AMOUNT REMITTED CHECK/MASH RE DYED, BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />3 ST)Z lc O, 00 0.573i- - ' ,_iti 1/457f 60- 1 g Li- - 34+ <br />0- <br />Pub. Health Serv. - EnvIro. 173 (1/97)