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- /4 <br />PHONE 1,5 <br />PFRIMC StNAL <br />Comment*: .5,3( ,e4:1.0.4._o-ee <br />CO IPLETED <br />APPLICATION FOR WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MAY 20 1999 <br />ENVIRONMENTAL HEALTH DIVISION <br />304 EAST WEBER AVENUE, STOCKTON, CA 9520a, UNV1 NIALri EA LT I- <br />(209) 468-3420 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete In TrIpliental <br />APPLICATION IS PIERS BY MADE TO THE SAN JOAOUIN 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 APN/ 15e,c) .4,414) /2424 <br />OWNER'S NAME <br />NEW WELL <br />0 INSTALLATION <br />0 New 0 Rep. <br />TYPE OF WELUPUMP: <br />CABLE OTHER <br />LOCKING CHESTER BOX/STOVE PIPE <br />AIR ROTARY AUGER X, <br />INTENDED USE <br />INDUSTRIAL <br />DOMESTIC/PRIVATE <br />PUBLIC/MUNICIPAL <br />IRFUGATION/A0 <br />..KMONITORING <br />APPROX. DEPTH <br />TYPE OF WELL <br />0 OPEN BOTTOM <br />0 GRAVEL PACK/SIZE <br />0 DRIVEN <br />0 OTHER <br />/in ( <br />0 FIRST WATER LEVEL <br />)54' SOIL BORING ) <br />OTHER <br />VAPOR EXTRACTION WELLS <br />A <br />DIA. OF CONDUCTOR CASINO <br />DIA. OF WELL CASINO Z <br />SPECIFICATION 2.6 4/0 <br />GROUT BRAND NAME 113/16/1, <br />CONCRETE PEDESTAL BY DRILLER: 0Y.. 0 No <br />\\_fj PROPOSED CONSTRUCTION/DRILUNG METHOD: MUD ROTARY <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATION AND THAT THE WOW MU. BE DONE DI ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES. STATE LAWS, AND RULES ANG-7, <br />REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR UCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH <br />THIS PERMIT IS memo, 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 WOW FOR WHICH THIS PERMIT IS ISSUED. I SHAU. EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />C AUFORNIA. A A T CALL 24 HO IN ADVANCE FOR ALL REOUIRED INSPECTIONS AT 12011) 401-31423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Slimed X Title Dat. <br />372 <br />REPLACEMENT WELL <br />WELL SYSTEM REPAIR <br />H.P. <br />(TYPE OF PUMP' <br />OUT-OF-SERVICE WELL <br />MONITORING WELL <br />CROSS-CONNECT REPAIR <br />DEPTH PUMP SET FT. <br />GEOPHYSICAL WELL S <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF WELL EXCAVATION <br />TYPE OF CASING/STEEUPVC <br />DEPTH OF GROUT SEAL g6.// /0.5- / <br />GROUT SEAL INSTALLED BY <br />GROUT SEAL SEAL PUMPED: 0Y.. IN, <br />PARCEL SIZEJAPN/ <br />("deem eo-v-,0/644."‘-s (7,77-67 9 ADDRESS 7-4140 16r 4'44-K14 A 04110-44' kt- PHONES <br />CONTRACTOR iraived le_aiL/t.--11,41,11--tai, ADoct(9946v5,v. 40/6304) a-4V PHONE I <br />SUB CONTRACTOR (b/41/172/ ADDRESS/134/ /o/&) <br /> <br />PLOT PLAN Mt'''. to %del Scale <br />NAMES OF STREETS OR ROADS NEAREST T BOUNDING THE PROPERTY. <br />OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. <br />DIMENSIONED CH/TUNES 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 OR PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS, <br />S. LOCATION OF WELLS WITHIN RAMS OF ONE HUNDRED FIFTY FT. <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />DEPARTMENT USE ONLY <br />Apollo/0.e Accepted By <br />tie4'7:t7 Grout Impaction By Purnp Inspection By <br />D.ttoctIon Impaction By <br />ACCOUNTING ONLY: AIDS FACO <br />PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH DATE PERNIITMIERVICE REQUEST NUMBER INVOICE <br />35o 1 NV ---- 2.130 0,,,IA_ <br />RECEIVED SY <br />„, Li-2_z ,,,,... it 2 4 <br />61R1:)0 / ei2.9 <br />' to <br />i„,, 5-- 2- t A.. 06E4' <br />Date <br />--714-4-70 OL_