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APPLICATION FOR WELLIPUMP PERM'` <br /> SAK%wOAOUIN COUNTY PUBLIC HEALTH SEI"ICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Tripiient6) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WrTll SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSOR APN# Za-5 _S.. &tjjA S-�y-��� CITY CLVL O\ <br /> OWNER'S NAME IPS . /'W.� pN S �F��7 s- \ � PARCEL 812E/APN/ <br /> y 1 ADDRESS X`J /� LakW-�� /� S PHONE#1 C9 8 Z^'�S�-5 <br /> CONTRACTOR T� y lM Y'T-'l� (� -���y1�`p� ADDRESS I A,.O(j'MIILL%U y",)r, '/� UCI S�� (-y PHONE I Z�+[�1 TI'2�Z+2"I <br /> SUBCONTRACTOR \ .�lr�\l\WAq ADDRESS 37-3-4 � PA. 0,.wUCX 6-4ZCo( / P14ONE OTU 8TZ-7-0 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ REPLACEMENT WELL J6t MONITORINO WELL# ❑OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# ,/ <br /> (TYPE OF PUMPI ❑New 13Repair H•P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0 <br /> 11OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ BOIL BORING R <br /> 11 DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> (l�� A <br /> A' <br /> INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION `O, DIA.OF CONDUCTOR CASINO MIA IA D <br /> ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/BTEEL/PVC Y DIA.OF WELL CASINO Z D <br /> ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL_ '� SPECIFICATION '5,- ,J. R <br /> ❑y IRRIGATION/AO ❑OTHER GROAT SEAL INSTALLED BY (lI f Y"L1aM@ GROUT BRAND NAME NQ4., rcR E <br /> )ISI MONITORING GROUT SEAL PUMPED:Oy- ❑No CONCRETE PEDESTAL BY DRILLER:❑Yea CgWo g <br /> APPROX.DEPTH & 35 LOCKING CHESTER BOX/STOVE PIPE_ s <br /> PROPOSED CON6TRUCTION/DRILUNG METHOD: MUD ROTARY AIR ROTARY_ AUGER CABLE OTHER <br /> 1 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:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH <br /> TRIG PERMIT 19 ISSUED,I 9I4ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'6 COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF <br /> CALIFORNIA." THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 1 f206)46$4423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Signed X C- / AN t, 4 ( Title A Ll_AA_C GLJV\,C,�u/`, Data I I, - q 7 <br /> PLOT PLAN(Draw to Scalel Scale 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4- LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPFRTY-GIVING OIMFNRIONR AND NORTHA wr-TY]N. nr <br /> 3. DIMENSIONED Olry FT. <br /> m <br /> STRUCTURES.INC 133N1S WOONI1 w z <br /> U M <br /> — —r) o W <br /> MCr Q w o <br /> r N Z <br /> r Z w J O W W <br /> 40 CL J N <br /> 3 Jpc� Q o0Q <br /> > a z V G✓ U• <br /> .. .. U o W d J - a IL 9 O <br /> M <br /> wa N U u <br /> w W Yr <br /> z (L O z ~ i- <br /> o <br /> V) Q IL Z z . <br /> W < <br /> 0 j 3 <br /> � o O � <br /> M CV o <br /> - a <br /> F <br /> a U <br /> � N ' <br /> 4 <br /> m m� <br /> 0 • m <br /> N <br /> w m <br /> o z <br /> 7 M O O <br /> - <br /> a a <br /> 3 .mn O <br /> J Z <br /> o <br /> 31N33 3 3 J x <br /> Z <br /> o < Z <br /> ON(nnO 30V80iS o m w n m <br /> o M E <br /> O it o 04 g <br /> .. ... in <br /> A311V p o <br /> Z <br /> Z - � �- 0- Tot L� w <br /> a <br /> W <br /> ?J38W(1N J P <br /> 'd£045606 <br /> t <br /> ONIMV80 _ <br /> DEPARTMENT USE ONLY 1 <br /> Application Accepted By / • ` - _ _.. Date_ 1` Q• Area <br /> Grout Inspection By Date Pwnp inspection By Data <br /> Oeatrtmtlon inspection By Data <br /> Comments. <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br /> it l 0 9 d! <br /> Pub.Health Serv.-Enviro.173(1/97) <br />