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CiAt PARCEL BIZE/APNX <br />o <br />CI OTHER <br />VAPOR EXTRACTION WELL <br />NEW WELL <br />INSTALLATION <br />0 New 0 Repel, <br />TYPE OF WELUPUMP: <br />(TYPE OF PUMP) <br />CABLE OTHER <br />GROUT SEAL PUMPED: DV.. 0 No CONCRETE PEDESTAL BY DRILLER: 0 Yee 0 No <br />LOCKING CHESTER BOX/STOVE PIPE <br />AIR ROTARY AUGER <br />APPLICATION FOR WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br />(209) 468-3420 <br />NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete hi Triplicate) <br />APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WON( DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />JOAOUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1 115,3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />9 T.crry <br />ADDRESS <br />DEPTH PUMP SET FT. FIRST WATER LEVEL 0 <br />0 0 UT-OF-SERVICE WELL 0 GEOPHYSICAL WELL 8 <br />lc 1 <br />.---- <br />JOB ADDRESS/OR AIN/ <br />OWNER'S NAME (-•? <br />CONTRACTOR d:)CLIL-1/4 ADDRESS <br />L,:( 510 L'-• S' 51--- PHONE <br />Vg_liS"F;i7 <br />hss 66-tfir UCX P10:1•1470 I/ 5 <br />TYPE OF WEU. CONSTRUCTION SPECIFICATIONS <br />0 OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASINO <br />0 GRAVEL PACK/SIZE TYPE OF CARING/STEEL/PVC DIA. OF WELL CASINO <br />0 DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br />0 OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME <br />El INDUSTRIAL <br />DOMESTIC/PRIVATE <br />PUBLIC/MUNICIPAL <br />CI IRRIGATION/AG <br />MONITORING <br />APPROX. DEPTH <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND nous AND <br />REGULATIONS OF .HE SAN JOAOUTP1 COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br />THIS PERMIT IS , T EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING/ 1 CERTJFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED. I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CAHN:MINA.' MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT (2001 4054422. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />int c,i-5,7 ,-Acrz_ oat. 2 /6147 t1- Clq Title Signed X <br />PLOT PLAN (Drew to &Wel Scale <br />NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. <br />OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. <br />DIMENSIONED °MUNE@ AND LOCATION OF ALL EXISTING AND PROPOSED <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS. AND WALKS. <br />LOCATION OF HOUSE SEWAGE DISPOSAL evirrus OR PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />S. LOCATION OF WELLS WITITIN RADIUS OF ONE HUNDRED FIFTY FT. <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />kL,/,) (Lr r(t <br />O.troctlen Inspection By <br />Cormnelir, O -e-52-A‘A&)" <br />A.& <br />Delo <br />0 Dim/ <br />Pump InopeetIon By Date ()Foul Impeetleft By <br />Aoplleetlen Accepted By <br />TEPArTMENT USE ONLY <br />7-1 <br />Dete <br />i <br />ACCOUNTING ONLY: AIDS _ FAC8 <br />PE CODES FEE INFO AMOUNT REMITTED I (CASH RECEIVED BY DATE PERMIT(S CE REQUEST NUMBER INVOICE <br />MO> (01 0 $1,)-0. I il ",ki 4-- 'd.-.A g ' 1 Cs/ 4-9 9 <br />60 <br />) <br />pvn,Ikkoi <br />, S 6 o (-) 1 <br />Pub Health Serv. - Enviro. 173 (1/97) <br />0 SOIL BORING <br />A <br />0 <br />0 <br />to <br />PAYMEN1 <br />pcinFn/Fr <br />APR .21999 <br />MONITORING WELL <br />CROSS-CONNECT REPAIR <br />ID REPLACEMENT WELL <br />El WELL SYSTEM REPAIR <br />H.P. <br />PROPOSED CONSTRUCTION/DRILUNG METHOD: MUD ROTARY