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YPE OF PUMPI <br />NEW WELL <br />INSTALLATION <br />0 Now 0 Repair <br />TYPE OF WELL/PUMP: 0 REPLACEMENT WELL <br />0 WELL SYSTEM REPAIR <br />H.P. <br />0 OUT-OF-SERVICE WELL <br />CROSS-CONNECT REPAIR <br />MONITORINO WELLS <br />DEPTH PUMP SET FT. <br />GEOPHYSICAL WELL S <br />OTHER <br />VAPOR EXTRACTION WELL <br />FIRST WATER LEVEL <br />91 SOIL BORING <br />MUD ROTARY AIR ROTARY AUGER CABLE OTHER PROPOSED CONSTRUCTION/DRILUNG METHOD: <br />to <br /> <br />PLOT PLAN Intew to Seetel Scale <br />I. NAMES OF STREETS OR ROADS NEAREST TO OR B THE PROPERTY. <br />OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. <br />DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. <br />I) <br />JOB ADDRESS/OR APN# ( lv, t_so 'Sroc-1:1-0 <br />ADDRESS 2: I WILC:JC)4 4\1 , 66'24 I <br />CyfIRACTOR ) u it* ADDRESS U)(,ij'Sc1 2.PHONEE scil'ckr"Fa441-1 Al CI- -re (7)TO LL oc_zei or, ADDRESS 7- Jci. PA DotiC--42 7 2_ PHONE i--2 -I <br />APPLICATION FOR WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />ORIGINAL 304 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 JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE VVIIII SAN <br />JOAQUIN COUNTY DEVELOPMENT TITLE. CHAPTER 9-1 1 1 5.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVI ES, ENVIRONMENTAL HEALTH DIVISION. <br />PARCEL 91ZEJAPNO <br />OWNER'S NAME CO LI E Htir-c) <br />0 DESTRUCTION: <br />INTENDED USE <br />INDUSTRIAL <br />DOMESTIC/PRIVATE <br />PUBLIC/MUNICIPAL <br />o IREUGATION/AG <br />.MONITORING <br />APPROX. DEPTH <br />CONSTRUCTION SPECIFICATIONS <br /> <br />fl/A. OF WELL EXCAVATION <br /> <br />a._TYPE OF CAIIING/STEEIJPVC k' \j <br />DEPTH OF GROUT SEAL <br />GROUT SEAL INSTALLED BY-1-17-,i GROUT BRAND NAME <br />GROUT SEAL PUMPED: altar Ne CONCRETE PEDESTAL BY DRILLER: 0 Yee Owe <br />LOCKING CHESTER BOX/STOVE PIPE Le C Id <br />A <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WON( WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS. AND RULES AP/13z_ <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 FERMI' IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORMA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br />THE FOU.DWING: I CERT THAT THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CAUFORNIA.' CALL URS IN ADVANCE FOR All REOUIRED INSPECTK/NS AT MOE 4111141421, COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Slimed X <br />ACCOUNTING ONLY: AIDE FACE <br />f I __.---- <br />PE CODES FE INFO AMOUNT REMITTED CHECKS/CASH REC :ED BY DATE PERMIT/SERVICE REGUEST NUMB INVOICE <br />550 / <br />;1A7 <br />30 <br />Aff&IMIEU'° /PY; -- .002.D2,3 <br />'I <br />A <br />ir rr r <br />le .' • <br />Pub Health Serv. - Enviro. 173 (1/97) <br />Title d , v L 11;_'-‘06 i IC E,E._ia- Date 5";11 21 7 1 , , <br />1--- <br />\A <br />(- <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 PT. <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />TYPE OF WEIL <br />0 OPEN BOTTOM <br />0 GRAVEL PACK/912E <br />0 DRIVEN <br />0 OTHER <br />DIA. OF CONDUCTOR CASING <br />DIA. OF WELL CASING <br />SPECIFICATION <br />2 " <br />il <br />Application Accepted By <br />Grout Impaction By <br />D.Irteellen In:mew/Ion By <br />Comments: <br />Date