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A <br />DIA. OF CONDUCTOR CASING NA <br />0 <br />DIA. OF WELL CASINO <br />SPECIFICATION <br />GROUT BRAND NAME ge. <br />nc.41 <br />V1+1)1(k; <br />CONCRETE PEDESTAL BY DRILLER: 0 Y. ON. <br />• <br />DEPARTMENT USE ONLY <br />Pump InttpoctIon By Dots 3 <br />DPI 3// /q9 Ass. t•O•P <br />Dote <br />ApplIcetten Accepted By <br />, ;c- <br />(trout Impaction By <br />Deetructlen Inopootloo By <br />Comment.: M <br />APPLICATION FOR WELL/PUMP PERMIT <br />JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />EAST WEBER AVENUE, STOCKTON, CA 95202 <br />(209) 468-3420 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete In Triplicate, <br />APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WON( DESCFUBED. THIS APPLICATION 18 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 APN8 <br /> <br />1-16ut-1-01,1 CITY st-oc k_+on PARCEL SIZEJAPNII <br />SAN <br />304 <br />FEP 19 <br />PERMIT <br />JOACVIAYI COV11+1 RA:11.1C, Ida rk_S ADDRESS OWNER'S NAME San <br />CONTRACTOR T ADDRESS 701 Pitric..Cryvkr Dr. <br />SUB CONTRACTOR 114134- 14842.14444 pea:AD Corp. ADDRESS 3233 S. <br />PHONE 8 C2.01) q6 8-3' <br />UCE PHONE 8...(2 9 <br />UCt PHONE 8 0/1))4038-1216 <br />18 I 0 EA cf 14-etztn- 0 rt <br />TYPE OF WELL/PUMP: <br />(TYPE OF PUMPI <br />0 DESTRUCTION: <br />El NEW WELL <br />0 INSTALLATION <br />0 New 0 Rooth <br />REPLACEMENT WELL X MONITORING WELL <br />0 WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR <br />H.P. DEPTH PUMP SET FT. <br />OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL S <br />OTHER <br />VAPOR EXTRACTION WELL S <br />FIRST WATER LEVEL <br />SOIL BORING <br />TYPE OF CASING/STEEL/PVC pyc rick <br />DEPTH OF GROUT SEAL ire 1:3e, <br />APPROX. DEPTH balk, 4'0 be Ins-I-Alta 04, cOn.borings G.14. LOCKING CHESTER SOX/STOVE PIPE <br />PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATION 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 UCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PEREOFIMANCE OF THE WON( FOR WHICH <br />THIS PERMIT 18 ISSUED. I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORMA. CONTRACTOR'S {BRING OR SUB-CONTRACTING SIGNATURE CERTIFIEB----_ <br />THE FOLLOWING: " 1 CE IFy THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS 0 <br />CAUEORNIA.' THE A CANT MUST CALL 24 HOURS IN ADVANCE FOR All. REQUIRED INSPECTIONS AT 120111 44111-3423. COMPUTE DRAWING AT LOWER AREA PROVIDED. <br />INTENDED USE <br />INDUSTRIAL <br />DOMESTIC/PRIVATE <br />o PUBUC/MUNICIPAL <br />IRRIGATION/AG <br />yl MONITORING <br />TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br />0 OPEN BOTTOM DIA. OF WELL EXCAVATION <br />GRAVEL PACK/SIZE 5 <br />0 DRIVEN <br />0 OTHER GROUT SEAL INSTALLED BY fAte,84 14an,NEA,+" <br />ett 50 GROUT SEAL PUMPED: eitYss ON. <br />Stoned X TItIo Data 2// c77 ) <br />to PLOT PLAN PLAN Prow to Boole' Seals <br />I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. <br />OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. <br />DIMENSIONED OUTUNEll AM) LOCATION OF ALL EXISTING AND PROPOSED <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. <br />LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />I. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />V St? <br />... <br />ACCOUNTING ONLY: AIDS FACE <br />PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECEIVED BY DATE PERMIT ERVICE REQUEST NUNISER INVOICE <br />5q .9.12. 66,24,/ j 14k— TA/95 .. i i <br />—7 -I-- - A f ,1/ F517 <br />"1"71 <br />__---) <br />Pub Health Serv. - Enviro. 173 (1/97)