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1645/71: ! FA9.,..4-,n7r <br />i <br />\c.':01 . 0 ,0 <br />z krt <br />'kg cr, <br />c. <br /><- 7 <br />5 <br />ZNO <br />(78 <br />CO c.n <br />.7) 171 rn <br />0 <br />1.1.1 3 m m Z 3 <br />11, <br />LL1 <br />APPLICATION FOR WELLIPUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 95201-388 <br />(2091 468-3420 <br />NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />if-ample* in Tripura) <br />APRUCATION IS HERE BY MADE TO THE SAN JOACIUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIB APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />JOAOUIN COUNTY DEVELOPMENT TI)LE, CHAPTER 9- 11 1 5.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY P.181.10 HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR ARNO 7735 S. RT 99 WEST FRONTAGEiryRD " STOCKTON PARCEL SIZE/APNA <br />OWNER'S NAME DAVID RAKOV ICH ADDRESS 5220 N. _ASHLEY ,STOEKTOkio NE II 952-3129 <br />CONTRACTOR HFNUNGS BROS. DRILLING CO. ADDRESS 3525 PEJ AMA, _Full° 29081:1., —ONE 4 545-1185 <br />SUB CONTRACTOR <br />TYPE of WELL/RUMP: al NEW WELL <br />D INSTALLATION <br />0 New On..., <br />LI REPLACEMENT WELL <br />0 VVELL SYSTEM REPAIR <br />H.P <br />0 MONITORING WELL • <br />o CROSS-CONNECT REPAIR <br />DEPTH PUMP SET FT. <br />0 OTHER <br />0 VAPOR EXTRACTION WELL <br />MGT WATER LEVEL <br /> <br />(TYPE OF PUMP) 0 OUT-Of-SERVICE WELL 0 GEOPHYSICAL WELL # <br /> <br />BOIL BORING <br /> <br />0 DESTRUCTION, <br /> <br />A <br />DA. OF CONDUCTOR CANNG <br /> 0\ <br />OM. OF WELL CASINO 10 " <br />ADEIREas <br /> LICO PHONE <br />INTENDED USE <br />0 INDUSTRIAL <br />0 DOMESTIC/PRIVATE <br />0 PUBLIC/MUNICIPAL <br />>13 IRRIGATION/AG <br />0 MONITORING <br />APPROX. DEPTH <br />TYRE OF WM,I, <br />DOPES BOTTOM <br />1:41 GRAVEL PACK/SIZE <br />0 DRIVEN <br />0 OTHER <br />CONSTRUCTION SPECIFICATIONS <br />NA. OF WELL EXCAVATION <br /> 20" <br />TYPE Of CASING/STEELPVC PVC <br />CONCRETE PEDESTAL BY DRIU.FR0 Vas No <br />DEPTH OF GROUT SEAL 100 1 . SPECIFICATION RFNTONITF <br />GROUT SEAL INSTALLS] BY HENN I NOS GROUT BRAND NAME <br />GROUT SEAL PUMPED. 0,••• . IN No <br />.."7.5c / <br /> <br />LOCKING CHESTER BOX/STOVE PPE <br />PROPOSED CONSTRUCTION/DRILL/NO METHOD: MUD ROTARY X AP ROTARY AUGER CABLE OTHER <br />THIS PERMIT 16 ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.. CONTRACTOR'S HIRING OR SUS-CONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOIMNG, ' I CERTIFY THAT IN THE PETIFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT PIE WORK WILL BE DOME IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AIND <br />REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR UCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: I CERTIFY THAT IN THE PERFORMANCE OF THE WOFN FOR WHICH <br />CAUFOFINIA - THE APPUCANI-MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 1205I 448 3. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Scrod kkalTAIN I\ .,.' • all . TIY Z--,--- ()—P-1 oe. M A Y 11, 1995 <br />PLOT PLAN IDyyw to SAPS Seals ' to <br />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 OUTUNES AND LOCATION OF ALL EXISTING AND PROPOSED 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />STRUCTUFES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> <br />DEPARTIMENT USE ONLY <br />-Dete - <br /> <br />peellon By AN-7e Date ,,571/,3„.4, 51,coop Inipemlon By <br /> <br />Dervuatlan ImpectIon By Celt <br />/76 /V <br />FACI -•••••••-• — <br />PE coo. FEB INFo <br />1 <br />AMOUNT REMITTED CHECKNCASH RECEIVED MY DATE <br />A <br />I VUTI E, INVOICE <br />4:36ct xic/ ky" 0-7,C•5— <br />rinar71A rECT LIMAER <br />—/--._Z.04„53.-- <br />SP‘ooklA00ii--