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/4— X _CO 1 <br />LIT/ r. <br />JOB ADDRESS/OR AM, <br />OWNER'S NAME <br />CONTRACTOR <br />SUB CONTRACTOR <br />REPLACEMENT WELL <br />WELL SYSTEM REPAIR <br />H.P. <br />TYPE OF VVELUPUMP: NEW WELL <br />INSTALLATION <br />El New 0 ROP•11 <br />CITY PARCEL SIZE/APNO <br />CONSTRUCTION SPECIFICATIONS A <br />DIA. OF WELL EXCAVATION DI . OF CON CTOR CASINO <br />TYPE OF CASING/STEEL/PVC DIA. OF WELL CASINO <br />TYPE OF WELL <br />0 OPEN BOTTOM <br />GRAVEL PACK/SIZE <br />4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />ON THE PROPERTY OR ADJOINING PROPERTY, <br />PLOT PLAN (Draw to Scale! Scale <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 OUTUNF.S AND LOCATION OF ALL EXISTING AND PROPOSED <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PAT/OS, DEVVEVVAYS, AND WALKS. <br />Application Aceepted By <br />Pump Impaction By Dete <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 />OW REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete in Triplicate) <br />APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORE DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN SAN <br />JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1 1 1 6.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SEFIV10ES, ENVIRONMENTAL HEALTH DIVISION. <br />(TYPE OF PUMP) <br />OUT-OF-SERVICE WELL <br />ONITOR/140 WELL # -k.L„; 0 OTHER <br />CROSS-CONNECT REPAIR <br />DEPTH PUMP SET FT. <br />GEOPHYSICAL WELL <br />DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> <br />0 OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME <br />ccf <br />AIR ROTARY AUGER CABLE OTHER <br />INTENDED USE <br />INDUSTRIAL <br />DOMESTIC/PRIVATE <br />PUBIJC/MUNICIPAL <br />IRRIGATION/AG <br />MONITORING <br />APPROX. DEPTH <br />Doetruction Inepection By <br />Comment*: <br />ACCOUNTING ONLY: AID/ FACO <br />-- <br />PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECEIVED BY DATE PIT/SERVICE REQUEST NUMBER INVOICE <br />3501_ 'zcl -0 ° $ c69. 00 \,04 -2_ -2- 1.15K001. ce c1 c1. <br />_..... _ <br />Pub Health Serv. - Enviro. 173 (1/97) <br />TO <br />PROPOSED CONSTRUCTION/DR/LUNG METHOD: MUD ROTARY <br />APR 2 .1999 <br />iNVIkuiNmENTAL HEALTH <br />oFnIvIIT / SERVICES <br />VAPOR EXTRACTION VVELL <br />FIRST WATER LEVEL <br />SOIL BORING <br />ADDRESS PHONES <br />ADDRESS 111(:) (5(-')C UC// •ZgiE. 3 2 ,/ -- <br /> ADMEN{ C-ik ki Li 53 :2,07 <br />NE <br />GROUT SEAL PUMPED: 0 Yee 0 No CONCRETE PEDESTAL BY DRILLER: 0 Yee 0 No <br />LOCKING CHESTER BOX/STOVE PIPE <br />I HEREBY CERTIFY THAT I HAVE PREP <br />REGULATIONS OF THE SAN JOA <br />THIS 19 ISSUED, I SHALL <br />THE F <br />CAIJF0 <br />Signed X <br />COU <br />T EMPLOY <br />T T IN THE <br />THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND <br />HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br />SONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORMA.• CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br />RMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED. I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />T CALL. 24 HOURS IN ADVANCE FOR AU, REOURIE0 INSPECTiONB T 120111 411*3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Title e Date 71-e/77 <br />Len A 1...t./1AAC.04-••••••• <br />Grout Inepoction By lk6AAA ( Zki‘i (,/bA44/(Ai1e <br />DEPARTMENT USE ONLY <br />Area