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OWNER'S NAME CA.11 0 5 t-CC-.1Z---11:1) <br />CONTRACTOR ATC /cc CLt_S - <br />SUB CONTRACTOR VitUi <br />JOB ADDRESS/OR APNE I Ito rst- 5t. too/ 175#3 CITY C 1\1-0(1 CA PARCEL SIZEJAPNO <br />ADDRESS 42)/.)' El bora-do t St-c&tt#1 <br />ADDRESS I7 cieblD LICE <br />ADDRESS R Bue.- 51 Rc Vst, tic/ 72.004 <br />91453 <br />PHONE ' 2C /9 37 -83-is <br />PHONE • 2(.11/S-ICl/ 4224 <br />PHONES 7C 7/3 - 2VI <br />REPLACEMENT WELL <br />WELL SYSTEM REPAIR <br />H.P. <br />.)<MONITOFUNG WELL E .2— 0 OTHER <br />CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELL <br />DEPTH PUMP SET FT. FIRST WATER LEVEL <br />(TYPE OF PUMPI <br />0 DESTRUCTION: <br />OUT-OF-SERVICE WELL GEOPHYSICAL WELL 0 SOIL BORING <br />PROPOSED CONSTRUCTION/DIVLUNG METHOD: MUD ROTARY AIR ROTARY AUGER X. CABLE OTHER <br />TYPE OF WELL/PUMP: NEW WELL <br />0 INSTALLATION <br />0 Neve 0 Repel, <br />CONSTRUCTION SPECIFICATIONS <br />A CI) DIA. OF WELL EXCAVATION <br />TYPE OF CASING/ST ER/PVC <br />DEPTH OF GROUT SEAL <br />TYPE OF WELL <br />0 OPEN BOTTOM <br />0 GRAVEL PACK/SIZE <br />0 DRIVEN <br />0 OTHER <br />S-c) <br />.P <br />GROUT SEAL INSTALLED BY 1.4.) <br />GROUT SEAL PUMPED: El Yes ON. fx1.- <br />LOCKING CHESTER BOX/STOVE PIPE 1JC <br />INTENDED USE <br />INDUSTRIAL <br />DOMESTIC/PR/VATE <br />PUBLIC/MUNICIPAL <br />IRRIGATION/AG <br />fit MONITORING <br />APPROX. DEPTH <br />A <br />DIA. OF CONDUCTOR CASING N (k•-• 0 <br />DIA. OF WELL CASINO Z Ade% <br />SPECIFICATION 3C41 <br />GROUT BRAND NAME C,e-nu-vv B E <br />CONCRETE PEDESTAL BY DRILLER: 0 Yee RNe <br />ApplIestIon Aeee01.4 BY <br />Grout Inepeetkm By <br />Lem N MA Cel <br />; I • <br />/ , - C, U. / Pump Inepeetlen By Date Dete <br />Dam Ars. <br />57--Ay APPLICATION FOR WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />304 EAST WEBER AVENUE, STOCICrON, CA 95202 <br />(209) 468-3420 <br />NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Memphis hi Triplicate) <br />APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE VV0F2( DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN <br />JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1116.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK 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: '1 CERTIFY THAT IN THE PERTORNIANCE 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 HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: I CERTIFY THAT IN THE PERFORMANCE OF THE YVON( FOR WHICH THIS PERMIT 18 ISSUED, I SHAU. EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CALIFORNIA.• THE APPUCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12081 4111S-2423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />P E TItIe 73 A citAkr_11 Date 2.12-4 /9 Cf <br />PLOT PLAN 113rew to Seats) Seale to <br />I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED <br /> I. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br />Elloneel X <br />ID <br />- - . - <br />0 <br />LI :SITE PLAN - 52574 0005 REBRuARY 1999 ON 3CATION NC WELL LOCAT1,-. 10 <br />z <br />0 <br />LL, <br />'i- <br />'7 r • <br />gc '6 1IL BORING LOCATI )NITORING WELL U GOOSED MONITOR! 3 I PUBLIC WORKS C RNIA • . • <br />.c: <br />--I. 7 2 ,. <br />' e L' 4.. 4' <br /> <br />Z. t C i _ <br />6 ',7, `-'. ,.-2' <br />/ 0 4 ,= „, F-0z <br />if-':- co c - Nc <br />_I <br />''. <br />00 <br /> 8 <br />2 t <br />00 <br />7., 11. 0 =11 <br />-'6-' L0 - z -_ <br />ft. <br />DEPARTMENT USE ONLY <br />Onetmetlen Impeetlon By <br />Commetee• <br />ACCOUNTING ONLY: AIDS FACE <br />PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />C6 1 ' °CI <br />( SiNb0 \PS2- LO 10 <br />Pub Health Serv. - Enviro. 173 (1/97) <br />Date