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Pub. Health Serv. - Enviro. 173 (3/96) <br />JOB ADDRESS/OR APN1 404 L. pacmc"rr- <br />OWNER'S NAME INS L- es,c-Am 1—.64A-7-TER_ <br />") <br />APPLICATION FOR WELLIPUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201-388 <br />(209) 4613420 <br />NOM-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete In Triplicate) <br />APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE VVORK 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 />crre3,5"rbr_iernhl <br />ADDRESS /041) -0 5 92o=Lel:gACANTA903 PHONES 9,6 -770() <br />ADDRESS?%/(.It•Mj) uc# 72.‘,(30 4/ PHONE # 7 7 ? <br />ADDRESS MCS <br />0 OTHER <br />0 VAPOR EXTRACTION WELL <br />FIRST WATER LEVEL <br />fieS011. BORING A <br />ZeD <br />INTENDED USE <br />0 INDUSTRIAL <br />DOMESTIC/PRIVATE <br />PUBLIC/MUNICIPAL <br />IRRIGATION/AO <br />,"MONITORING <br />APPROX. DEPTH <br />DEPTH OF GROUT SEAL 5- <br />TYPE OF CASING/STEEL/PVC 1/1 plies <br />- 5--o0 Dote <br />4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM on 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 />PLOT PLAN (Drew to Boatel Boole <br />NAME OF STREETS OR ROADS NEAREST TO OR BOUNDING 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 />AUG <br />PARCEL SIZE/APNS <br />CONTRACTOR <br />SUB CONTRACTOR <br />PHONE I' <br />TYPE OF WELL <br />0 OPEN BOTTOM <br />0 GyVEL PACK/SIZE <br />WRIVEN <br />0 OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF WELL EXCAVATION 2 <br />GROUT SEAL INSTALLED BY 1"Rdendr$4 <br />GROUT SEAL PUMPED: RlYes ONe CONCRETE PEDESTAL BY DRILLER: 0 Yes No <br />DIA. OF CONDUCTOR CASING AL,4 <br />DIA. OF WELL CASING y <br />SPECIFICATION 84/ ciiC;) <br />GROUT BRAND NAME <br />LOCKING CHESTER BOX/STOVE PIPE <br />Title 544J/012. 4rKbete7 7[Cc-e57 -- Stoned X <br />(A0-,s <br />-411/ 1 hoc OA es Irb / <br />Data <br />Dote <br />Kfrt g4i21 <br />ACCOUNTING ONLY: AIDS FACII <br />...., <br />PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECEIVED BY DATE INVOICE ITAIEFIVICE REQUEST NUIVISEE1 <br />3 501 gq .00 19965 1 Vr / sp 0 0 23 cii-1- Ai- r <br />0 REPLACEMENT WELL <br />0 WELL SYSTEM REPAIR <br />H.P. <br />0 OUT-OF-SERVICE WELL <br />to <br />0 <br />A <br />MONITORING WELL S o CR095 CONNECT REPAIR <br />DEPTH PUMP SET FT. <br />0 GEOPHYSICAL WELL <br />DEPARTMENT USE ONLY <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />Comments. <br />p Inspection By <br />12(ktecs. C.DC017D4 <br />X *P9,09ose.i, L-r -OP17.0W - ADCATio..1 <br />TYPE OF WELL/PUMP: 0 NEW WELL <br />El INSTALLATION <br />0 New 0 Repair <br />(TYPE OF PUMP' <br />0 DESTRUCTION: <br />z