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AID! F A C# ACCOUNTING ONLY; <br />FEE INFO <br />cc/66 <br />AMOUNT REMITTED CHECKMASIT <br />16701/ <br />RECEIVED BY DATE <br />4/7t 1)1/ <br />PEFINIIT/IETIVICE REQUEST numnEn <br />SgL.5o2 ei <br />INVOICE <br />PE CODES <br />DEPARTMENT USE ONLY <br />2 02_ Ares <br />)PLICATION FOR WELL/PUMP PERMh <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <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 />(Oomph(' In Triplicate) <br />APPLICATION IS IIERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A Krum TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE VVI111 SAN JOAOUIN COUNTY DEVELOPM , TITLE. CHAPTER 9-1116.3 AND THE STANDARD!) OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />r <br />JOB ADDRESS/OR APR! / 1 7-- N . ci.4 11,--0 /1-042.-- CITY -Cilx--e2hm PARCEL SIZE/A7! / 4 3 '''/ II"' 25 <br />OWNER'S NAME Leu----:,-- P, rea 5 i'61-4,-.: , <br /> <br />ADDRESS/'/L Al Sil.„4- 7<fr,....) 711A./2-- PlION°E # 5. go 3 -737 -527 3' <br />CONTRACTOR etCA•i- IC-- kj...e.- 1 i ..-e...._ <br />SUB CONTRACTOR <br />ADORES 2021/E e"--.--11.0-1-4cr-f- ktk-feic if C57 /40/ PHONE 0 2-69. 467 Z ---7‘27‘. <br />ADDRESS LIC# PHONE! <br />TYPE OF WELL/PUMP; 0 NEW WELL 0 REPLACEMENT WELL 0 MONITORING WELL! 0 OTHER 0 INSTALLATION 0 WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELL! D Now 0 Repair H.P. DEPTH PUMP SET r-r. FIRST WATER LEVEL 0 (TYPE OF PUMPI <br />0 OUT-OF-SERVICE WELL 0 GEOPHYSICAL WEIL ,1 <br />EcKESTRUCTION: WI (Z "e--"" / 6e-#14I-ten 'IL ‘O.F1 p Lif2-242-.. <br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br />0 INDUSTRIAL 0 OPEN BOTTOM .2 .4 <br />.--?. DIA. OF WELL EXCAVATION DIA. or CONDUCTOR CASINO • 0 <br />El DOMESTIC/PRIVATE LX....RAVEL PACK/SIZE TYPE OF CASING/).VC CA y DIA. OF WELL CASINO 63/%1C h 0 El7PLIC/MUNICIPAL 0 DRIVEN DEPTH OF amour SEAL SPECIFICATION 1 R 1.7 dr IRRIGATION/AG 0 OTHER GROUT SEAL INSTALLED BY a:2(-1 lite-y- onotrr BRAND NAME S Ct."... ...__F 0 MONITORING GROUT SEAL PUMPED: O N. CONCRETE PEDESTAL BY DRILLER: 0 Y.. ON, S <br />APPROX. DEPTH (An 43 A <br />j2K <br />LOCKING CHESTER SOX/STOVE PIPE S <br />I./ PROPOSED CONSTRUCTIONIDRILUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br />hEnEnv CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND <br />REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF TIIE vvonk FOR WHICH THIS PERMIT IS ISSUED, ',MAIL 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 WOPK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CALIFORNIA.' T E 6bP4leCmA,NT MUST CALL 24 HOURS IN ADVANCE FOR ALL REGUIRED INSPECTIONS AT 12011 41114423. COMPUTE DRAWING AT LOWER AREA PROVIDE <br />Stoned X Title 0j/ SY— Owe <br />PLOT PLAN 113rew to Seale) Seale • to I. NAMES or STREETS on ROADS NEAREST TO OR BOUNDING THE Pnorenry. <br />OUTLINE OF THE PROPERTY, ERVING DIMENSIONS AND NORTH DIRECTION. <br />DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS. DRIVEWAYS, AND WALKS. <br /> <br />LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM on PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />5, LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />ON THE PROPERTY on ADJOINING PROPERTY. <br /> <br />A00081100 Accepted By <br />Grout Ineeoctloo By Dote Pony Impaction By <br />Deeloseilen !need-Mon By 44-4,-. <br /> Delo <br />Comm-wrote:I SCA-C-,k-; co,...k ct1A.e.A„.7t- <br />oec oe\ <br />0 SOIL nonirro <br />— 546-1`e /06- pAVL-724 bk. <br />Dit• <br />Pub. Health Serv. - Enviro. 173 (1/97)