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NEW WELL <br />INSTALLATION <br />New 0 Repair <br />TYPE OF WELL/PUMP: <br />(TYPE OF PUMP) <br />GEOPHYSICAL WELLS 0 SOIL BORING OUT-OF-SERVICE WELL <br />0 DESTRUCTION! <br />" to <br />4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM on 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 />NOT PLAN (Draw to Boole) Scale <br />I. 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 /> Pump InopectIon By Data <br />A <br />0,..1 Impaction By -ezv--67 <br />Destruction Inspection By <br />Comment.. WO la &ALL WEV-12.1144,1 come refliu-e_ci CsDyttvetciw-ss r-LLe <br />APPLICATION FOR WELLIPUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIuES <br />ENVIRONMENTAL HEALTH DIVISION <br />P.O. BOX 388,304 EAST WEBER AVENUE, STOCKTON, CA 85201 -388 <br />(209) 468-3420 <br />REPLACEMENT WELL <br />WELL SYSTEM REPAIR <br />H.P. <br />El MONITORING WELL / - 0 OTHER <br />CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELL S <br />DEPTH PUMP SET IT. FIRST WATER LEVEL <br />CONSTRUCIION SPECIFICATIONS <br />DIA. OF WELL EXCAVATION DIA. or CONDUCTOR CASING <br />TYPE OF CASING/S1EE4V_:q DIA. OF WELL CASING 2 p„ <br />DEPTH OF GROUT SEAL (i 5 r f. SPECIFICATION AI Iv i K' -1 (1 <br />GROUT SEAL INSTALLED BY '-i r t' /1i ' C. GROUT BRAND NAME P6,, 1-/..,, ', <br />GROUT SEAL PUMPED: Dyed. No CONCRETE PEDESTAL BY DRILLER! 12 Yro• 0 No <br />LOCKING CHESTER BOX/STOVE PIPE N A <br /> AIR ROTARY AUGER ./ CABLE OTHER <br />INTENDED USE <br />INDUSTRIAL <br />DOMESTIC/PRIVATE <br />PUBLIC/MUNICIPAL <br />IRRIGATION/AG <br />MONITORING <br />APPROX. DEPTH <br />PROPOSED CONSTRUCTION(DRILUNG METHOD: MUD ROTARY <br />A <br />LI <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE VVORK 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 W011( FOR WHICH <br />THIS PERMIT 18 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: ' !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 <br />CALIFORNIA.' THE APPLICANT MUST CALL 24 HOUR N ADVANCE FOR ALL REQUIRED INSPECTIONS AT 120111 44111-3423, COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Signed X Title Lilo v. 4,, f I 41 , t- Data I 7 <br />DEPARTMENT USE ONLY <br />ACCOUNTING ONLY: AIDS FACE <br />PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />C)1 .it 6 1tp13 viw_7)0,- tz.(1.1‘, SPloot t t 3( <br />Pub. Health Serv. - Enviro. 173 (3/96) <br />Application Accepted By /11 12.q.c/C, Area <br />Dela <br />CONTRACTOR e <br />SUB CONTRACTOR <br />fr-C PI VI t 4 ri rf <br />r: E. c. <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete In Triplicate, <br />SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN CHAPTER 9-1115.3 AND TilE STANDARDS or SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />PARCEL SIZE/APN/ <br />APPLICATION IS HERE BY MADE TO THE <br />JOAOUIN COUNTY DEVELOPMENT TITLE, <br />JOB ADDRESS/OR AMU/ <br />OVVNEITS NAIVIE M. J 4% <br />1-1 6 "I k rti1c A Gi <br />ti44t, <br />) o Fop, <br />6 VGi II .s A tvk' ufa (I PHONES 146 . It21 ADDRESS <br /> <br />ADDRESS /10 kitf H eirt. 1,1 1—ti ..ScjAJCI 6Yd 2_2_ 7 PHONE 2 01 Y.5/t.- <br /> <br />ADDRESS 3.b• 5pr: ei l peoc,a, tic/5 PHONE /I-YU -%if, -7:5 71 <br />CITY <br />/11 C <br />TYPE OF WELL <br />OPEN BOTTOM <br />N GRAVEL PACK/SIZE <br />El DRIVEN <br />El OTHER