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INTENDED USE <br />INDUSTRIAL <br />DOMESTIC/PRIVATE <br />0 MIX/MUNICIPAL <br />IRRIGATION/AG <br />MONITORING <br />APPROX. DEPTH <br />TYPE OF WEU. <br />0 OPEN BOTTOM <br />0 GRAVEL PACK/SIZE <br />0 DRIVEN <br />0 OTHER <br />PROPOSED CONSTRUCTION/DRILUNO METHOD: MUD ROTARY <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 />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete ho Trip Rental <br />APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE YVON( DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />JOAOUIN COUNTY DEVELOPMENT TITLE. CHAPTER 9-1 1 15.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />PARCEL SIZEJAPNO <br />OWNER'S NAME iii)APiCA1- r-4U1 P r1FAir RFAI7A-L- <br />CONTRACTOR Ft 5e-11- Etv'V I g.t2 r\"4-1 Er"' L- <br />SUS CONTRACTOR <br />ADDRESS <br />739 ,5,i+ER <br />ADDRESS V y s P:3 <br />ADDRESS <br /> PHONE I./.3 --73-0-1 <br />uc• PHONE P -T7IR'-;a57O <br />UCl/ PHONE I <br />TYPE OF WELL/PUMP: 0 NEW WELL <br />0 INSTALLATION <br /> 0 Now El Repoli <br />(TYPE OF PUMP) <br />0 DESTRUCTION: <br />REPLACEMENT vont <br />o WELL SYSTEM REPAIR <br />H.P. <br />OUT-OF-SERVICE WELL <br />MONITORING WELL <br />CROSS-CONNECT REPAIR <br />DEPTH PUMP SET FT. <br />GEOPHYSICAL WELL <br />OTHER <br />VAPOR EXTRACTION WELL S <br />FIRST WATER LEVEL <br />SOIL 15011/NCe (af) <br />0 <br />JOB ADDRESS/OR AMIN 4.71 (It 40../ cn crry aPlig CA <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF WELL EXCAVATION 2 <br />TYPE OF CASING/STEEL/PVC <br />DEPTH OF GROUT SEAL-MTN— OLP rg <br />GROUT SEAL INSTALLED BY DR 1-f-E-4 <br />GROUT SEAL PUMPED: 0 Yoe 0 No <br />LOCKING CHESTER SOX/STOVE PIPE <br />AIR ROTARY AUGER <br />DIA. OF CONDUCTOR CASINO <br />DIA. OF WELL CASING <br />SPECIFICATION <br />GROUT BRAND NAME <br />CONCRETE PEDESTAL BY DRILLER: El Yea 0 No <br />CABLE <br />OTHER DiRer Pvsit <br />I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APP1JCATION 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 UCEN8ED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOFK FOR WHICH....„... <br />THIS PERMIT 18188 SHALL NOT EMPLOY MOONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA. CONTRACTOR'S HIRING 011 RUB-CONTRACTING SIGNATURE CERTIFIES <br />THE FOU.OW1NG:CERTIFY THAT IN THE FIFORM 1i( FOR WHICH THIS PERMIT 18 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF ----. <br />CALIFOPNIA. jlir APPV CANT MUST Oa 4 HO FOR ALL REQUIRED INSPECDONS AT 12051400-)422. COMPLETE DRAWING AT LOWER AREA PRO D. <br />i ... ./ <br />Tit?. p G kD ._31 C Hc., 26J-t 0..7 Z,F 97 <br />PLOT PLAN (Drew to Boole' Scala to <br />NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. <br />OUTLINE OF THE PROPERTY. GIVING DIMENSIONS AND NORTH DIRECTION. <br />DIMENSIONED °MUNE@ 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 RADIUS OF ONE HUNDRED FIFTY FT. <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />5:FE 77-14Q+4ED SCTE <br />Signed X <br />... <br />....... • <br />......... <br />ApplImitton Am/opted By IC YtAA4 /-121 <br />Grout IneportHou By (1111'.4.-AAn'sed."1 <br />DEPARTMENT USE ONLY <br />Dots CESI 50(tm Pump Impaction By <br />Dote <br />Dommetlen Inopoodon By <br />Comments: <br />ACCOUNTING ONLY: AIDE FACE <br />PE CODES FEE INFO AMOUNT REMITTED CHECK/MASH RECEIVED BY DATE PERMIT/SEFIVICE REQUEST NUMBER INVOICE <br />3 col Isi,00 0 o9 7-15— 1 5 ti 11 oxo 01 _ <br />Pub Health Serv. - Enviro. 173 (1/97)