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ADDREBS UCf PHONE 9 <br />TYPE OF WELL/PUMP; <br />J <br />HP. FIRST WATER LEVEL O <br />SOIL BOntNCl n <br />A <br />OIA. OF WEIL EXCAVATION DIA. OF CONDUCTOR CASING n <br />TYPE OF CASING/STFFl/PVC DIA. OF WELL CASING n <br />PUBLIC/MUNICIPAL DEPTH OF GROUT SEAL SPECIFICATION A <br />IRRIGATION/AG <br />E <br /> NoMONITORINGGROUT SEAL PUMPED:(ZJno 5 <br />APPROX. DEPTH LOCKING CHESTER ROX/BTOVE PIPE <br />PROPOSED CONSTRUCTION/DRUUNG METHOD: MUD ROTARY <br /> <br />AIR ROTARY AUGER CARLE OTHER <br />O <br />9 <br />SlonM X Title Date <br />’ te <br />.4... <br />i-Ii......I <br />•i <br />DEPARTMENT USE ONLY <br />57Application Accepted By.Date Area <br />F/e^/77Orotrt Inspection By >te Ptimp Inspection By Date <br />Dnstrnctlon Inspection By Date <br />Comments: <br />ACCOUNTING ONLY:AID,FAC, <br />PE CODES FEE INFO AMOUNT REMITTED TIECI /CASH RECEIVED BY PERMIT/IERVICE REQUEST NUMBffl <br />o <br />Pub. Health Serv. - Enviro. 173 (1/97) <br />1111 i»J <br />i.. <br /><BKoP^ <br />INVOICE <br />VZ M.OT BARN (Draw to Sooto) Roolo <br />1. NAMFR or RTnEETS OR ROADS NEAREST TO OR BOUNDINO THE fRorERTY. <br />t. OUTLINE OF THE morERTY. OIV1NO DIMENSIONS AND NORTH DIRECTION. <br />3. DIMENSIONED OUTLINES AND LOCATION OF All EXIRTINO AND PROPOSED <br />STRUCTURES, INCIUDINO COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, ANO WALKS. <br />HIE rotlOWJHOt • I CERTITY THAT IN Tiff <br />CAUTORNlX? TH <br />EE <br />LOCATION OP HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />EXPANSION OF SEWAOE DISPOSAL SYSTEMS. <br />LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED TITTY FT. <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />! <br />1. <br />APPLICANT MUST <br />TYPE OF WELL "* <br /> open bottom <br /> GRAVEL PACK/SIZEj. <br /> DRIVEN <br /> OTHER <br />DATE <br />feeo-r —- <br />HYPE OF PUMPJ <br />ri / ^<7 7 A <br />PPLICATION FOR WELUPUMP PERM A <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SElWcES <br />ENVIRONMENTAL HEALTH DIVISION <br />304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br />(209) 468-3420 <br />; ■■■ i ■ <br />GTroiTT BRAND NAME <br />CONCRETE PEDESTAL BY DRILLER: Y— <br />GROUT SEAL INSTALLED BY <br /> y- <br />AUG 2 6 1997 <br />j : i * i : ; <br />i san Joaquin couniy : <br />fh <br />I <br />APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY TOR A PERMIT TO CONSTRUCT <br />JOAOUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1 1 15.3 AND THE STANDARDS OF SAN “ <br />JOB ADORESS/OR APNF \c>loo^ L <br />OWNFH B NAME \|QA <br />CONTRACTOR Cf\uo C CYYX'OA x <br />Ad/A <br /> NEW WELL <br /> INSTALLATION <br />PHnew D Repair <br />~j----------------------"<one r <br />i ad co < Vjo < kXc, i <br /> REPLACEMENT WELL <br /> WELL SYSTEM REPAIR <br /> MONITORING WELL S <br /> CROSS CONNECT REPAIR <br />DEPTH PUMP SETLilin <br /> OUT Or-SERVICE WELL <br />tlOM REFUMDABie PERMIT EXPIRES 1 YEAR PHOM DATE ISSUED <br />(Complsts In Tripneatsl <br />-----------------1 AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />) OF SAN jpylUIN COUNTY PUBLIC HEALTH SERVICES. ENVIRONMENTAL HEALTH DIVISION. <br />/TH) K^t'ctTY Z.Typ? <br />ADDREs4^ (3 I / xOyT Q <br />ADDRESS Q | <br /> OTHER <br /> VAPOR EXTRACTION WELL f <br />-2^ <br />RFGULATION8 OF THE BAN JOAOUIN COUNTY. 1'“*------------------------------------------------- <br />THIS PERMIT IB IBBUED, I SHALL NOT EMPLOY PER6ONB SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.’ <br />PERFORMANCE OT THE WORK TOR WHICH THIS PERMIT IS ISSUED. I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S <br />24 HOURS IN ADVANCE FOR ALL REOUntD INjagCTIONS AT (IOS) 4SS-M2S. COMPLETE DRAWING AT LOWER AREA PROV1| <br />yiOJC/lh <br />■ PAYMENT <br />• r RECFJVED <br /> GEOPHYSICAL WELL » <br />1HP Si.U..p¥Wl <br />“~J CONSTRUCTiON SPECIFICATIONS <br />( HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION ANO THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAOUIN COUNTY ORDINANCES, STATE LAWS AND RULES Alm <br />HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: ’I CERTIFY THAT IN THE PERFORMANCE OF THE WOIX TOR WHICH <br />zr contractor s hiring or sub contractino signature certihes <br />S COMPENSATION IAWS or <br />Rovideo. / ;y/6p7 <br />PARCEL BIZE/APNf <br />PHONE 93^33^0 <br />INTENDED USE <br />JJ^INOUSTRIAL <br /> OOMESHC/PRIVATE