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MPPLICATION FOR WELL/PUMP PERAI� <br /> SA AQUIN COUNTY PUBLIC HEALTH S CES <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 Triplicate) <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 WRIT SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER B-1115.3 AND THE STANDARDS OF SAN"AMIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSMR APNe 3931 Newton Road CITY Stockton PARCEL SIZE/APHe <br /> OWNER'S NAME Gillies TRuckingADDRESS PO Box 8303 PIIONEF 948-6268 <br /> CONTRACTOR Clark Well , Inc . ADDRESS 2024 E Charter tJce 371560PHONE0462-7676 <br /> SUB CONTRACTOR ADDRESS PIC! PHONE <br /> TYPE OF WELL/PIMP: ❑ NEW WELL ❑ REPUCEMENT WELL 11 MONITORING WELL R 11 OTHER <br /> F� ❑ INSTALLATION 1Yq WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL F J <br /> IS V ❑New❑Repel, N.P. II DEPTH PUMP SET—FT. FIRST WATER LEVEL O u <br /> (TYPE OF PVMPI <br /> ❑ OUT-OF6ERVME WELL ❑ GEOPHYSICAL WELL A ❑ 601E BORNO S <br /> ❑DESTRUCTION: v <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ^ <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO O <br /> 44 DOMESTICA'WVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEIJVC DIA.OF WELL CASINO D <br /> ❑ PIIBUCRJUNICMAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R _ <br /> ❑ IRRIGATION/AG OTHER GROUT SEAL INSTALLED BY BMW BRAND NAME E <br /> ❑ MONITORING 1 1 GROUT SEAL PUMPED: ❑Yr ❑N. CONCRETE PEDESTAL SY DRILLER:❑Yw ❑N. 5 <br /> APPROX.DEPTH " E LOCKING CHESTER BOX/STOVE PIPE S <br /> PROPOSED CONSTRUCTIONRNBLUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> C <br /> I HEREBV CERT THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES.STATE LAWS.AND RULER ANO _ <br /> REGULATIONS THE SAN JOAOUIN COUNTY. HOME OWNER O ICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CEWIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PEnMIT I 1 SLED,I SHALL T OV R NO SUBJECT O WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR BUS-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOW 1 CERTIFY T 1 PIE ANCE OF WOR(FOR WHICH THIS PERMIT 19 ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN <br /> I COMPdSAT10N LAWS OF <br /> CAUFORNIA.' PP CA T 1 N ADVA E FOR ALL REGUIRED INSPECTONe AT ICCAN SM4Y/21. COMFLETE DRAWING AT LOWER AREA PROVIDED. <br /> 61.x% Till. Sec-Tres D.I. 10/15/97 <br /> PLOT PLAN Mfr t.%001 S..1. 't. <br /> 1. NAMES OF STREETS OR ROA EAMST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 1}\ <br /> Z. OUTLINE OF THE PROFERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> J. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. 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 PIGPERTY. <br /> 0000. ... ... <br /> O{ _ 0000 <br /> v .. <br /> X <br /> PAYMENT <br /> G <br /> tE4CtVD <br /> ... <br /> _. , OCT 2141997 <br /> 0000 <br /> SN J"A(]UIN f 1 <br /> i ? i PV 'GALTH S r � <br />