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0 DESTRUCTION.
<br />(TYPE OF PUMP)
<br />Rrl....3011. soma* I *),159 /
<br />/17 5-5 ih y
<br />0 OUT-OF-SERVICE WELL 0 GEOPHYSICAI WELL
<br />0 CROSS-CONNECT REPAIR
<br />DEPTH PUMP SET 0
<br />0 MONITORING WEIL 0 REPLACEMENT WELL
<br />0 WELL SYSTEM REPAIR
<br />H.P.
<br />o OTHER 0 VAPOR EXTRACTION WELL 0
<br />FIRST WATER LEVEL
<br />TYPE OF WELL/PUMP: 0 NEW WE?L
<br />0 INSTALLATION
<br />0 New 0 Ropolr
<br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A
<br />0 INDUSTRIAL 0 OPEN flOTTOM (GA. OF WELL EXCAVATION ,.., o, CONDUCTOR CASINO a
<br />0 DOMESTIC/PRIVATE 0 GRAVEL PACK/SIZE TYPE OF CASING/STEELJPVC DIA. OF WELL CASINO 0
<br />0 PUBLIC/MUNICIPAL 0 DFUVEN DEPTH OF GROUT SEAL SPECIFICATION A
<br />0 IRRIGATION/AG 0 OTHER GROUT SEAL INSTALLED BY ...UT BRAND NAME
<br />0 MONITORING GROUT SEAT ,..,••,•, Dv.. Os. CONCRETE PEDESTAL BY DRILLER: D v... 0 No S.
<br />APPROX, DEPTH LOCKING CHESTER BOX/STOVE PIPE
<br />PROPOSED CONSTRUCTION/DRILLINO METHOD: MUD ROTARY AIR ROTARY AUGER CARTE OTHER Pe 'pe, c-1-/245/1 $
<br />APPLICATION FOR WELL/PUMP PERMIT
<br />i;. VIC II:
<br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES
<br />ENVIRONMENTAL HEALTH DIVISION , •
<br />P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA'46201-388 Tli
<br />(209) 4583420
<br />NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE Iii6EQCT 30 0 6 (Complete hi Triplicits)
<br />APPLICATION IS HERE we MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL TILE WORE DESCRIBED, THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN
<br />JOAOUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9.1116.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES. ENVIRONMENTAL HEALTH DIVISION.
<br />JOB ADDRESS/OR APN0 z6/4/0 N. The,t-h1-o" Road PARCEL RIZE/APFLIC7.. -/3-0
<br />,,c,„„,.„k3/6 /04,4ide/rairai/cs, orq5P,Z,t`li V6/-33/(
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<br />OWNERS NAMEerST A1-445 Cigit9/
<br />CONTRACTOR )41 (Hit recAfird(29r Co 7)')m fia ADDRESS (Ct 41/142/6/4 Oci.....6/11)/Y2/ P110112057 2-/
<br />SUB CONTRACTOR x ....4-etumeittoi 5ertio_s ADDRET115:5-.CAESS /241 6irThq/P70.5- 92.7 „d/1286-/(4
<br />I HEREBY CERTIFY THAT I HAVE PREPARED TIIIS APPLICATIONAND THAT DIF WORK WIlt RE DO RD M NE IN ACCORDANCE MITI RAN JOAOUIN COUNTY 0111)INANCES, STATE lAWS, AND nut.. AND
<br />REGULATIONS OF TILE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORE FOR WHICH
<br />THIS PERMIT IS ISSUED. I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN•S COMPENSATION LAWS OF CAIIFORNIA. CONTRACTOR'S IIIRINO DR SUBCONTRACTING SIGNATURE CERTIFIES
<br />CALIFORNIA.• THE APPLICANT MUST CA 24 HOURS IN ADVANCE FOR ALL REOUIPIFIT INSPECTIONS AT (20161 4..3423. COMPLETE DRAWING AT LOWER AREA PROVIDED.
<br />THE FOLLOWING: • I CERTIFY THAT IN THE PERFORMANCE OF THE WORK For, WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF
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<br />OT PLAN !Draw to ScaIel Scale
<br />1 NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY.
<br />2 OUTLINE OF TILE PROPERTY, GIVING DIMENSIONB AND NORTH DIRECTION.
<br />3 DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED
<br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS. AND WALKS.
<br />
<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 OR ADJOINING PROPERTY.
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<br />Mono/ X A • Ala L.! t a., EI •
<br />Application Accept./ By 14/0
<br />DEPARTMENT USE ONLY
<br />Grout Inspection By
<br />Destruction Inspection By
<br />C 3rnTnent/, CXV5I/C- k1V1e.5ficietilbe) 24,03 D-fhorntori
<br />Oats Pump Inspection By Dote
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<br />ACCOUNTING ONLY: AIDS FACE
<br />PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECEIVED BY DATE M7LMITISERVICE REQUEST NUMMI INVOICE
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