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El NEW WELL <br />0 INSTALLATION <br />0 New 0 Rectal! <br />TYPE OF WELL/PUMP: <br />(TYPE OF PUMP) <br />CI SOIL BORING 0 GEOPHYSICAL WELL OUT-OF-SERVICE WELL <br />INTENDED USE <br />INDUSTRIAL <br />DOMESTIC/PRIVATE <br />PUBLIC/MUNICIPAL <br />TYPE OF WELL <br />0 OPEN BOTTOM <br />0 GRAVEL PACK/SIZE <br />0 DRIVEN <br />SAIrAOUIN COUNTY PUBLIC HEALTH SEl ;ES <br />PLICATION FOR WELL/PUMP PERMIT <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 />(Comptes In TripRental <br />APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/011 INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MARE IN COMPLIANCE WITH SAN <br />PARCEL SIZE/APNI/ <br />:5PM ADDRESS )73-7) PHONE S <br />CONTRACTOR V •vN) DRILLWIr <br />SUB CONTRACTOR De L- 6-e-51 Er—P-niC4CLNDonEss100--q ()1..i OE ME Pictiff A3k),,,,,,,,„(2A)%91413-7 <br />ADDRESS Co (3trx. 5 I Ectb -1/Ott 3)4rgir-, <br />JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1 1 1 5.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH eEnvicEe. ENVIRONMENTAL HEALTH DIVISION. 37 W Li 00-6 RI*C, CITY We'll JOB ADDRESS/OR APNS <br />OWNER'S NAME <br />WELL SYSTEM REPAIR <br />11 MONITORING WELLS I CFI'. 0 OTHER 0 REPLACEMENT WELL <br />CROSS-CONNECT REPAIR <br />H.P. DEPTH PUMP SET FT <br />0 VAPOR EXTRACTION WELL <br />0 <br />0 DESTRUCTION: <br />CONSTRUCTION SPECIFICATIONS <br />0 <br /> <br />111 V Cs, DIA. OF WELL CASING 6CP' <br /> SPECIFICATION R <br /> <br />GROUT SEAL INSTALLED BY V **I GROUT BRAND NAME <br />CONCRETE PEDESTAL BY DRILLER: 0 Yea 0 No <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATION AND THAT THE VVORK 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 LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br />THIS PERMIT 19 ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S mniNo OR SUB CONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWIN : I CERTIFY THAT IN THE PERFORMANCE OF THE VVORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CALIFORNIA. 4t APPtJCNT 4SjCALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12091 4511-9423. COMPLETE DRAWING AT LOWER AREA PROVIDE . <br />Slonerd X <br /> <br />PLOT PLAN (Drew to Scale) Boole <br />NAMES OF STREETS OR ROA FARM 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 /> PAYMENT- <br />AN 1-2 1999 <br />SA1,' nAC( <br />.HEALTHSEIRViCe'Eb: ENVIRONMENTAL HEALTH rPLIS)Ot, <br />Date Pump Inapeetlon By <br />Dela <br />V ilAMA <br />tWPA/ i1114/ Des 114 <br />DEPARTMENT USE ONLY <br />(),•olroctlen InerectIon By <br />Corornent•: <br />Application Accooted By <br />Grout Inspection By <br />Des 1H 1/ Area <br />ACCOUNTING ONLY: AIDS FACE <br />PE CODES r FEE INFO AMOUNT REMITTED CHECKS/CASH RECEIVED BY DATE PEFUVIIT/AUDRCEREQUEST-NUPASSR--.... <br />"'"'",.....,.., <br />INVOlef <br />iirov i,6 f ip-ico <br />Pub. Health Serv. - Enviro. 173 (1/97) <br />DIA. OF CONDUCTOR CASING NIA, <br />IRRIGATION/AG 0 OTHER <br />'MONITORING <br />c. <br />APPROX. DEPTH 3 GROUT SEAL PUMPED1*Yee 0 No <br />LOCKING CHESTER BOX/STOVE PIPE <br />PROPOSED CONSTRUCITON/DRIILUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br />Title DC1_76144-- 1 15 `it) <br />-JAN 0 8 1999 <br />FIRST WATER LEVEL <br />DIA. OF WELL EXCAVATION <br />TYPE OF CASING/STEEL/PVC <br />DEPTH OF GROUT SEAL <br />to <br />4. 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 on ADJOINING PROPERTY.