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TYPE OF WELUPUMP: <br />(TYPE OF PUMP) <br />NEW WELL <br />INSTALLATION <br />0 New 0 Repo), <br />MONITORING WELLS <br />CROSS-CONNECT REPAIR <br />DEPTH PUMP SET FT. <br />0 REPLACEMENT WELL <br />0 WELL SYSTEM REPAIR <br />GROUT BRAND NAME <br />CONCRETE PEDESTAL BY DRILLER: 0 Yee 0 No <br />GROUT SEAL INSTALLED BY <br />GROUT SEAL PUMPED: 0 Yee 0 No <br />LOCKING CHESTER BOX/STOVE PIPE <br />,16 eZei/";iik Title Signed X <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 UCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 1 CERTIFY THAT IN THE PERFORMANCE OF THE VVOFIK FOR WHICH <br />TH18 PERMIT IS ISSUED, 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 WOIVC FOR WHICH THIS PERMIT 18 ISSUED, I /MAU. EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CAUF011/41A.* THE APYWCAPYI MUST eA HOURS IN ADVANCE FOR ALL REOUIRED INS DONS AT 12001 400-3421. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Dale <br />LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />PLOT PLAN (Drew to Scale) Sc. <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 COMMIES AND LOCATION OF ALL EXISTING AND PROPOSED <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WAU(S. <br />t/3 <br />Dote <br />Pub Health Serv. - Enviro. 173 (1/97) <br />-7v c_lc s 84-1,frt /44_04 • 15kaktclf- 4 s -4-0 o <br />JOAOUIN COUNTY DEVELOPMENT <br />yo <br />TITLE. CHAPTER 9-1 115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH BERMES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR APNS 0)6f A./44 : e_ cry'- - q57)-0? PARCEL SIZE/APNI <br />le is d'A Dub 1 ;Al Ill/hOotkS'AppnEs. 5'4 e_ PHONE 94'6 SS)69 <br />OWNER'S NAME <br />CONTRACTOR t y Zit; If ADDRESS 0. BOA' 44L UCt7279_3 X:t? PHONES 36/9 ;4 77 ei <br />SUB CONTRACTOR ADDRESS UCS PHONE I <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 />NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete In Triplicate) <br />APPLICATION IS 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 WITH SAN <br />ttE <br />... <br />DEPARTMENT USE ONLY <br />Apollo/4ton Accepted By <br />(trout Inspection OT <br />Tcco <br />Date <br />z <br />- LAre-C" (1) A- <br />Ot2.5i; L.? erg! eeezii' 11.3-51,a..4..,...k tn 56;4" 4 .- le Ac•-e-1---12c <br />Destruction Inepectloe By <br />ACCOUNTING ONLY: AIDS PACS j.0 4-714.-471..' <br />i <br />PE CODES FEE INFO AMOUNT REMITTED /CAM RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBEFI INVOICE <br />4-/#6 4 'LD *6411 I <br />35V P-41 la) .Z-, ----- LW kig e_t3 11 It <br />to <br />Date /(/r?/ '17 <br />Area <br />Purnp Inspection By Date <br />Lt../0 <br />d i'vc <br />VAPOR EXTRACTION WELL S <br />/ 0 OUT-OF-SERVICE LL 0 GEOPHYSICAL WELL # <br />/ e4si ft Pi , ilc 745" f_ct/Ti 14 DESTRUCTION: <br />0 <br />INTENDED USE TYPE OF WELL <br />INDUSTRIAL 0 OPEN BOTTOM <br />DOMESTIC/PRIVATE 0 GRAVEL PACK/SIZE <br />PUBLIC/MUNICIPAL 0 DRIVEN <br />IRRIGATION/AG 0 OTHER <br />MONITORING <br />APPROX. DEPTH ? <br />PROPOSED CONSTRUCTION/DRILUNG METHOD: MUD ROTARY <br />OTHER <br />FIRST WATER LEVEL e/29 0 <br />SOIL BORING <br />r tli Y 6* 71;.9 fepAw _e <br />A <br />DIA. OF CONDUCTOR CASINO <br />DIA. OF WELL CASING <br />SPECIFICATION <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF WELL EXCAVATION <br />TYPE OF CASING/STEEL/PVC <br />DEPTH OF GROUT SEAL <br />AIR ROTARY AUGER CABLE OTHER