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0 REPLACEMENT WELL <br />0 WELL SYSTEM REPAIR <br />El OUT-OF-SERVICE WELL <br />CROSS-CONNECT REPAIR <br />MONITORING WELL <br />DEPTH PUMP SET FT. <br />GEOPHYSICAL WELL a <br />TYPE OF WELL/PUMP: 0 NEW WELL <br />0 INSTALLATION <br />0 Now 0 Repel/ <br />(TYPE OF PUMP) <br />0 DESTRUCTION: <br />OTHER <br />VAPOR EXTRACTION WELL <br />FIRST WATER LEVEL <br />R. SOIL BORING ffh.ey <br />A/4 TYPE OF CASING/STEELJPVC <br />DEPTH OF GROUT SEAL <br />GROUT SEAL INSTALLED BY <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 />PLOT PLAN (Drew to 13oelel 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 />Date Date Grout Inspection By Pump Inspection By <br />Date Destruction Impaction By <br />ce... See Ptisigtir) <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF WELL EXCAVATION <br />GROUT SEAL PUMPED: 0 Yee ErNo <br />LOCKING CHESTER BOX/STOVE PIPE <br />AIR ROTARY AUGER <br />DIA. or CONDUCTOR CASING VA /0 <br />DIA. OF WELL CASING /1,4- <br />SPECIFICATION AM- <br />GROUT BRAND NAME/Z47/44) te-MOir E <br />CONCRETE PEDESTAL BY DRILLER: 0 Yee laRo <br />Alo <br />OTHER se,)r - <br />INTENDED USE <br />INDUSTRIAL <br />DOMESTIC/PRIVATE <br />PUBLIC/MUNICIPAL <br />IRRIGATION/AG <br />MONITORING <br />APPROX. DEPTH <br />TYPE OF WELL <br />0 OPEN BOTTOM <br />0 GRAVEL PACK/SIZE <br />0 DRIVEN <br />Id OTHER opr" <br />/407,9-41 <br />PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY CABLE <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPIJCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN 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 WORK 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 PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CALIFORNIA.' PPUC NT ST ALL 24 140 IN ADVANCE FOR AU. REGUIRED INSPECTIONS AT 1209) 409-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Slowed X Title P4/CC-2-- Date Y. 7-97 <br />........-1/1 Application Accepted <br />DEPARTMENT USE ONLY <br />By Dot. T.2 2 . q --- Area <br />APPLICATION FOR WELLIPUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICts <br />ENVIRONMENTAL HEALTH DIVISION <br />P.O. BOX 388,304 EAST WEBER AVENUE, STOCKTON, CA 95201-388 <br />(209) 468.3420 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete In Triplicate) <br />APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />JOAOU1N COUNTY DEVELOPMENT TITLE, CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAOU1N COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR AMR Zu z, CITY PARCEL SIZE/APOU/ 6-hciel, <br />OWNER'S NAME /471,44X-1.2 Z74'2 <br />CONTRACTOR /5117/i/94a—PAteflidea&lAitifer/3/L, ADDRESB" 11! /finecht 744.A.A.1227 PHONE 9/0---a241 <br />SUB CONTRACTOR ADDRESS A:4 <br />7Z24) '...C-e26 <br />LICSI <br />ACCOUNTING ONLY: AIDS FACO <br />PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECEIVED BY DATE PERMIT/SERVICE REOUEST NUMMI INVOICE <br />ZO i 1 M 102 / Yik919-7 __....-34-1 32_ <br />Pub. Health Serv. - Enviro. 173 (3/96) <br />ADDRESS i?/7 14p;04e.* PHONE I/ 1:67—. 43'52r <br />PHONE //