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Grout Inspection By KIV1/41-')( Date I/ S <br />Destruction Inspection By <br />A-I ‘i-4J. zet <br />Application Accepted By 74/kdA4A)-q f Date <br />Pump Inspection By <br />Comment,: <br />DEPARTMENT USE ONLY <br />Date <br />Date <br />APPLICATION FOR WELLIPUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />RO, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201-388 <br />(209) 468-3420 <br />0 oWS78-- <br />PARCEL SIZE/APN# Z73"'" 130 13 <br />OWNER'S NAME C. IA evirovs- civ cf-s C A00RESSF.'11 S(t.) 1"/ CY1 <br />9 r3 PHONE ef 2-- <br />Itt 1-161 uct Z7-0 7-93 PHONE II .T1-1 'CFO <br />CONTRACTOR ewe,- - ADDRESS c 4c, ,ysz .57 <br />ADDRESS t.5 tA) <br />/0111[45 <br />IL° >C22-/ 2-5 pi4oNc?1"-}8gY -21 I AM.411 ,WW11 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Campine in Triplicate) <br />APPLICATION IS 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 />JOAOUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR APN# e) frl — 5 tretz-i- CITY <br />(acracTop- ator. ., <br />TYPE OF WELL/PUMP: ID NEW WELL <br />0 INSTALLATION <br />o New 0 Repalr <br />REPLACEMENT WELL <br />0 WELL SYSTEM REPAIR <br />H.P. <br />0 MONITORING WELL # <br />0 CROSS-CONNECT REPAIR <br />DEPTH PUMP SET FT. <br /> <br />OTHER <br /> <br />VAPOR EXTRACTION WELLS <br /> <br />0' <br />u?) <br /> <br />FIRST WATER LEVEL <br /> <br />(TYPE OF PUMP) <br /> <br />OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL # 0 SOIL BORING <br />O DESTRUCTION: esvt, ,:tiv 62.4 (')1j I gee-suvvle ftvidcrv•-c di t <br />t( <br />INTENDED USE TYPE OF WELL <br />INDUSTRIAL 0 OPEN BOTTOM <br />DOMESTIC/PRIVATE p GRAVEL PACK/SIZE <br />PUBLIC/MUNICIPAL 0 DRIVEN <br />IRRIGATION/AG 0 OTHER <br />/ <br />El MONITORING / Welt' --. PI <br />APPROX. DEPTH 47/ tv a Is - ad ' <br />PROPOSED CONSTRUCTION/DRILUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF WELL EXCAVATION y <br />DIA. OF CONDUCTOR CASINO <br />TYPE OF CASING/STEEL/PVC I5Ch. V /1/-6- DIA. OF WELL CASING <br />DEPTH OF GROUT SEAL S / SPECIFICATION R <br />GROUT SEAL INSTALLED BY <br />GROUT BRAND NAME <br />E <br />GROUT SEAL PUMPED: CI Yee 0 No <br />CONCRETE PEDESTAL BY DRILLER: DY.. 0 No <br />LOCKING CHESTER BOX/STOVE PIPE <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND <br />REGULATIONS OF THE SAN JOAOUIN 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 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 RFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CALIFORNIA.' T APPUCANT MU9 CA 4 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT QM 4611.3423. COMPLETE DRAWING AT LOWER AREA PROVI ED. <br />/ 467. <br />Title ..-4111Ar 6er(71.5#4-. Dee ZS/91 <br />PLOT PLAN (Draw to Seele) Scale / to 410 / <br />NAMES 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 />Signed X <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 />ACCOUNTING ONLY: AIDS FAG/ <br />—I <br />f <br />PE CODES FEE INFO AMOUNT REMITTED C C /CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />T D-z__ , op <br />C-SCkbp