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El GEOPHYSICAL WELL S El SOIL BORING <br />SPECIFICATION R <br />GROUT BRAND NAME k <br />CONCRETE PEDESTAL BY DRILLER: NY. 0 No <br />•••4*.. S <br />NEW WELL <br />INSTALLATION <br />0 New 0 Repair <br />TYPE OF WELL/PUMP: <br />(TYPE OF PUMP) <br />Signed X <br />MONITOFUNG WELLS MeV ""' 6 0 OTHER <br />0 CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELL / <br />DEPTH PUMP SET FT. FIRST WATER LEVEL <br />0 DESTRUCTION: <br />CONSTRUCTION SPECIFICATIONS f <br />CABLE OTHER b <br />.5- Z f <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCAT/ON AND THAT THE VVOPK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND <br />REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH <br />THIS PERMIT 18 ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA. CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIER <br />OF THE WOW FOR WHICH THIS PERMIT IS ISSUED. I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CAUFORNIA.' THE 4PfLICANT MUST CALL 24 HO DVANCE FOR ALL REQUIRED INSPECTIONS AT 1201114111-2422. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Title PrC'j 'f-C1- ‘ec3Loji s: ° i S8v2- Date .,3 -3t) —0 f <br />(1) <br />THE FOLLOWING: I CERTIFY THAT /N THE PERFORMA <br />DIA. OF VVELL EXCAVATION $' tr: 5 <br />Y; TYPE OF CASING/STEEL/PVC -:3/6C 101t e__ <br />DEPTH OF GROUT SEAL <br />GROUT SEAL INSTALLED BY .-K.c..447 Ac.6 <br />GROUT SEAL PUMPED: RN's. 0 No <br />LOCKING CHESTER SOX/STOVE PIPE <br />AIR ROTARY AUGER itstos-41 <br />1-0 .5 ' <br />DIA. OF CONDUCTOR CASING <br />DIA. OF WELL CASING y.,) <br />PROPOSED CONSTRUCTION/DRILUNO METHOD: MUD ROTARY <br />REPLACEMENT WELL <br />WELL SYSTEM REPAIR <br />H.P. <br />OUT-OF-SERVICE WELL <br />INTENDED USE <br />INDUSTRIAL <br />DOMESTIC/PRIVATE <br />PUBLIC/MUNICIPAL <br />IRRIGATION/AG <br />MONITORING <br />APPROX. DEPTH <br />TYPE OF WELL <br />OPEN BOTTOM <br />KGRAVEL PACK/SIZE <br />0 DRIVEN <br />OTHER <br />Cc_c_70- <br />CITY r—itTn-de--e4 PARCEL SIZEJAPNS ..20 q - .24,0 -2_,, <br />-:i•Sc-7 aak...-p,,s c_ ./--; <br />;•=...-c-4-4,,,-,6 c2,4 9441 E).- 74, , PHONE ,s;t-, L.74, <br /> <br />ADDRESS 661-3.4.4-, filoal. , CA ILICE PLIONEV9m; <br />ib .dx, la, f C_pvte-....... p -• e. 41 4 <br /> <br />vx .1 5",--/-6.' Iv c s' 7 f.c/Z d <br /> <br />ADDRESS i z i r h,....yz.....e, <br />f <br />VJ CA UCN/D3&2 3E7 PHONES .2_17- eefic <br />cf`MOci< <br />ADDRESS OWNER'S NAME QL.J.IL te4C-15 <br />C RACTOR C :TAX_ <br />sun CONTRACTOR pv.,- 6.4.,-,r4 , <br />JOB ADDRESS/OR APN/ // cr4., s c <br />" to <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 />PLOT PLAN Prow to Soolol Boole <br />I. NAMES OF STREETS OR ROADS NEAREST TO on 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 />DEPARTMENT USE ONLY <br />Delo Area <br />Delo Date Pomp Inspection By <br />.1E' CA- ‘•-• Application Accepted By <br />Grout Inspection By <br />Destructlen Inspection By <br />Comments: <br />ACCOUNTING ONLY: AIDS FACE <br />PE CODES FEE INFO AMOUNT REMITTED CHECK/MASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUSAIBR - INVOICE <br />3 CC) 1 9 • VC -,32_3-tj <br />4 6 I 00 <br /> <br />,.., "mom <br />1., • - b <br />Pub Health Serv. - Enviro. 173 (1/97) <br />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 />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete hi TripDental <br />APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PEFIMIT TO CONSTRUCT AND/011 INSTALL THE VVOW DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />JOAQUIN COUNTY DEVELOPMENT TITLE. CHAPTER 9-1115.3 AND THE STANDARDS OF SAN X/AOUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />APR 2 2 001 <br />ENV I Flu • <br />P ER '0 IT