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'APPLICATION FOR WELL/PUMP PERM'-'\ <br /> ­'\ <br /> SA"AQUIN COUNTY PUBLIC HEALTH SEI,4'CES <br /> 1 ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,STOCKTON, CA 95202 <br /> (209)468-3420 <br /> o NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' <br /> (COMPlata IR TrlpRcala► <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> I JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-11119.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> I <br /> JOB ADDRESS/OR APNA `_ C+4 . y')1 CITY_ -� - r <br /> tS s r( ia' r• ^ PARCEL 81ZE/APNO <br /> OWNER'S NAME J^i7w,I� �,il�A1 t ADDRESS <br /> f`�11t �a j�C)� <br /> - r"� <br /> PHr <br /> 11 ONE <br /> CONTRACTOR_[ w, ADDRESS IfI nu nj. fjtt it14L YI ��r� UC# O"C.7.Z 1 PHONE <br /> SHB CONTRACTOR _,_LE' li .'?r �1f)(1 t ALr Iri'�3tii��!fl-�Q 1 ADORE68 �r n i LIC (~t L PHONE# jP �'U;}.y 1•�i <br /> - rr {!� - ••1 C - 74 <br /> TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ' <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL 0 <br /> ❑New 11Repalr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) O <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL 8 SOIL BORING S-3 <br /> El DESTRUCTION: <br /> INTENDED USE TYPE OF WELLCONSTRUCTION SPECIFICATIONS A <br />�. ❑ INDUSTRIAL ❑OPEN BOTTOM <br /> DIA.OF WELL EXCAVATION �- �/':',r„ DIA.OF CONDUCTOR CASINO � •~ p <br /> I ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC_ 1� �+.' DIA.OF WELL CASING L/r p <br /> ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL:U j!. I �� ')r� SPECIFICATION h. R <br /> ❑ IRRIGATION/AG 11OTHER_„ OROUT SEAL INSTALLED BY_:l(I,'At d pnY GROUT BRAND NAME _(•J I b,} -) j! E <br /> ❑ MONITORING _ GROUT SEAL PUMPED:MY. (IN. p CONCRETE PEDESTAL BY DRILLER:0Y. [IN. S <br /> APPROX.DEPTH C,. ' +' 1' ld, ✓ LOCKING CHESTER BOX/STOVE PIPE 'W ;_ <br /> S <br /> PROPOSED CON"UCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> v <br /> I HEREBY CERTIFY THAT, HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH CAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE CAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMITS ISSUED,1814ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN-S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: -I CERTIFY-THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REGURRED INSPECTIONS AT 12001 408-2423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Bllned X .r,. -}. �� - 1 Tltle T� r i /- <br /> _ ': t 1�C`Jr-,�11 9 1 Datep I <br /> r <br /> PLOT PLAN(Draw to Scale)goal. 'to ' <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. ' <br /> 3. 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 PROPERTY. <br /> Ijr <br /> ..... :.. . .. . <br /> ..:... ..:.. ...:.. .:.. ...... .:.. <br /> ....... .... .. .'..... �. ... ...�.'.....-.......`..!fir.�. . <br /> >.... . .. .............. _ .-...;..... .......................... :...... . .... .. .....►1. .1�. ... . ..;...J.;.. .. .... .: <br /> _.... ............... ............ .. <br /> ... ...;.... .. 4 ..... ......:..... .. .. .. .. ... .. ..... ........ ....... <br /> .w�.. ................................................................... <br /> - If% <br /> ( DEPARTMENT USE ONLY <br /> Appltentl.n Aeeepted BY �/ / �i l .! \- -�.+-'�- Dete <br /> a+ �� <br /> j Grout bmpeetlon By Date Pump Inapeetlen By Date <br /> Demlrtmtlen Inmpectlon BY Date <br /> C.mm.nta• <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODED FEE INFO AMOUNT REMITTED Cu #/CASH RECEIVED BY DATJE PEHMITISERVICE REQUEST NUMBER INVOICE <br /> i <br /> Pub.Health Serv.-Enviro.173(1/97) <br /> i <br />