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CONSTRUCTION SPECIFICATIONS <br />DIA. OF WELL EXCAVATION <br />TYPE OF CASING/STEEL/PVC <br />DEPTH OF GROUT SEAL 2C <br />GROUT SEAL INSTALLED BY Dr)I let <br />APPLICATION FOR WELLIPUMP PERM' <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SE..-aS <br />ENVIRONMENTAL HEALTH DIVISION <br />P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201-388 <br />(209) 488.3420 <br />NON•REFUNDADLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1 1 1 5.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR APNI/ i 5 It' Cht/7-iri- tt) <br />APPLICATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />eci --1 <br /> <br />(CompIgo in Tripling& <br />SUB CONTRACTOR <br />ADDRESS <br />TYPE OF WELL/PUMP: <br />(TYPE OF PUMP) <br />0 DESTRUCTION: <br />)t NEW WELL <br />INSTALLATION <br />0 New 0 Repair <br />REPLACEMENT WELL <br />WELL SYSTEM REPAIR <br />H.P. <br />OUT-OF-SERVICE WELL <br />/ MONITORING WELL // 1.k'— <br />CROSS-CONNECT REPAIR <br />DEPTH PUMP SET FT. <br />0 GEOPHYSICAL WELLS <br />0 OTHER <br />P/VAPOR EXTRACTION WELL S <br />FIRST WATER LEVEL 0 <br />SOIL BORING <br />CITY <br />PARCEL SIZE/APNS <br />OWNER'S NAME .----OLle1/4.1 P 0(i le-br) <br />CONTRACTOR OC; I ell), ti arks erN t!' utc(s) <br />ADDRESS I (kV S Linen i?t,11 Alebik PHONE 712- 057/ <br />ADDRESS I I 1:53 Ri 0 ie. ':11(1:11.4- PHONES3O/ <br />UCS <br />5,5zt -76 <br />PHONES <br />INTENDED USE <br />El INDUSTRIAL <br />DOMESTIC/PRIVATE <br />PUBLIC/MUNICIPAL <br />IRRIGATION/AG <br />)4 MONITORING <br />APPROX. DEPTH <br />TYPE OF WELL <br />0 OPEN BOTTOM <br />0 GRAVEL PACK/SIZE <br />0 DRIVEN <br />0 OTHER <br />GROUT SEAL PUMPED: 0 Yes 0 No <br />LOCKING CHESTER BOX/STOVE PIPE <br />MUD ROTARY AIR ROTARY AUGER <br />DIA. OF CONDUCTOR CASING <br />DIA. OF WELL CASING <br />SPECIFICATION <br />GROUT BRAND NAME <br />CONCRETE PEDESTAL BY DRILLER: CI Yes CINo <br />CABLE OTHER PROPOSED CONSTRUCTIONIDRIWNO METHOD: <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APF1JCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AN , <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 WON( FOR WHIGS( <br />THIS 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 WOW FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CALIFORNIA. • T APPUCANT MUST U. 24 HOURS IN ADVANCE FOR AU. REQUIRED INSPECTIONS AT 120111441S-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />/ <br />E/23/q1 Signed X (& id i (Z td Title fh)i ed--- 6ederi I it — Date <br />.1' <br />PLOT PLAN (Draw to Scala) Scale ' 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 OUTUNFS 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 />4-VaLhe <br />Application Accepted By <br />Grout Inspection By <br />1,441D <br />DEPARTMENT USE ONLY <br />Date CkjA 7 Pump Inspection By <br />Date Area <br />Date <br /> <br />Deetruction Inspection By Date <br />Comments: <br /> <br />ACCOUNTING ONLY: AIDS FACE _.-"Rcc, r‘; <br />PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUIVIB — <br /> yr <br />INVOICE <br />6O1 A %°r 4iNC\ --CI-A6.122CL--W Si7A-Iii. '010VAo