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Application Accepted By <br />Grout Inspection By <br /> <br />Destruction Inspection By, <br />Comments: <br />EPARTrAT USE ONLY <br />C*-- <br />Date 411 Cd4C1 PurkflpectIon By <br />Date V?! CL CI Area ,K1-0 <br />Date <br />Date <br />••••• <br />61i t <br />1 ACCOUNTING ONLY: AIDS , ,ACir <br />, <br />,3--Ri,(")/6-ii—v 4 <br />PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECEIVED BY I DATE PIIRMIT,SI;FIVICE REQUEST NUMBER INVOICE <br />?("i _i 00 L !1 -6.0d. l'q:ACM i (- I Ci-sq-0-2--- <br />I <br />REPLACEMENT WELL <br />WELL SYSTEM REPAIR <br />H.P. DEPTH PUMP SET FT. <br />OTHER <br />VAPOR EXTRACTION WELL a <br />FIRST WATER LEVEL <br />MONITORING WELL a 3 <br />CROSS-CONNECT REPAIR <br />OUT-OF-SERVICE WELL <br /> O GEOPHYSICAL WELL a )11, SOIL BORING <br />TYPE OF WELL/PUMP 0 NEW WELL <br />CI INSTALLATION <br />CI New 1:1 Repair <br />(TYPE PUMP) <br />0 DESTRUCTION' <br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br />O //s-r <br />APPLICATION FOR WELL/PUMP PERIVIl'i <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201-388 <br />(209) 468-3420 <br />CONTRACTOR <br />OWNER'S NAME 'TED pE-TeR --ria44.1m6- ADDRESS i r13 5 %fel- -mryt- 1. 0, <br />SUB CONTRACTOR D Etn sEt4i-nle-ie-L, ADDRESS ob cspii...fik, RA <br />V4-4 pf,ILLig ADDREss 5 IRIg <br /> <br />CITY tAkYITEM <br />fx461,4 *li <br /> PARCEL SIZE/APN# <br />A <br />0 INDUSTRIAL 0 OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING D <br />CI DOMESTIC/PRIVATE 0 GRAVEL PACK/SIZE TYPE OF CASING/STEELJPVC DIA. OF WELL CASING D <br />PUBLIC/MUNICIPAL 0 DRIVEN DEPTH OF GROUT SEAL SPECIFICATION a <br />IRRIGATION/AG 0 OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br />..XIMONITORING ot E 1 GROUT SEAL PUMPED: 0 Yen 0 No CONCRETE PEDESTAL BY DRILLER: Dyes 0 No S <br />APPROX. DEPTH'IMF? LOCKING CHESTER BOX/STOVE FIFE S <br />PROPOSED CONSTRUCTION/DRILUNG METHOD: MUD ROTARY AIR ROTARY AUGER *, <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION 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 LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br />THIS PERMITS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br />THE FOLLO G: " I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CALIFORNIA." THE AP A T ST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12051408-3423. COMPLETE DRAWING AT LOWERREA PROVIDED.13 <br />Title fiN ti I.Y5 -Lbrk-- efirlTri407:6-R.01 it i <br />PLOT PLAN (Draw to Scale) Scale " to <br />. NAMES OF STREETS OR DS 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 OR ADJOINING PROPERTY. <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete M Triplicate) <br />APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN 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 APNift 5 I rVel &Iv D <br />PHONE 7-39 49 Lirl <br />.A PHONE a 1034z115 <br />,j) i3 PHONE #2,17 <br />CABLE OTHER <br />Signed X