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SUB CONTRACTOR ADDRESS <br />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 />(TYPE OF PUMP/ <br />MONITORING WELL K <br />CROSS-CONNECT REPAIR <br />DEPTH PUMP SET FT. <br />GEOPHYSICAL WELL <br />TYPE OF WELL/PUMP: <br />5 1 <br />INTENDED USE <br />INDUSTRIAL <br />DOMESTIC/PRIVATE <br />PUBLIC/MUNICIPAL <br />IRRIGATION/AG <br />MONITORING <br />APPROX. DEPTH <br />DIA. OF CONDUCTOR CASING <br />A <br />DIA. OF VVELL CASING <br />SPECIFICATION <br />GROUT BRAND NAME <br />CONCRETE PEDESTAL BY DRILLER: El Yes 0 No <br />t <br />4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS, <br />6. LOCATION OF VVELL9 WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />PLOT PLAN (Drew to %solid Scale <br />NAMES OF STREETS OR nonos 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 />Comments: U.41/1. .70 S" [ f CilwE C_-5-1 I- ce.4 tji An b ktaDd <br />ACCOUNTING ONLY: AIDS/ FACK <br />IJCK PHONE K <br />OTHER <br />VAPOR EXTRACTION WELL S <br />FIRST WATER LEVEL <br />teSOIL BORING <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF WELL EXCAVATION <br />TYPE OF CASING/STEEL/PVC <br />DEPTH OF GROUT SEAL <br />.Q.A— GROUT SEAL INSTALLED BY <br />GROUT SEAL PUMPED: El Yes El No <br />LOCKING CHESTER BOX/STOVE PIPE <br />TYPE OF WELL <br />0 OPEN BOTTOM <br />0 GRAVEL PACK/SIZE <br />0 DRIVEN <br />MOTHER VN1C.1....‘e<Sk <br />1441211, <br />Application Accepted By Date Area <br />Date Grout Inspection By Date Pump Inspection By <br />Destruction Inspection By Date <br />DEPARTMENT USE ONLY <br />PAYMENT <br />RECEIVED <br />JUL 2 0 998 <br />SAN JOAQUIN COUNTY <br />PUBLIC HEALTH seRvicEs <br />ENVIRONMENTAL HEALTH DIVISION <br />PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />7/1.0 ( CCel ---- J0(1)