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,ow <br />1PPLICATION FOR WELL/PUMP PER <br />SA.--OAQUIN COUNTY PUBLIC HEALTH SE ICES <br />ENVIRONMENTAL HEALTH DIVISION <br />xcolwyl <br />304 EAST WEBER AVENUE, STOCKTON, CA 95202 (j}M <br />(209) 468-3420 <br />1110111 -REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED / <br />(Complete In TFlplkatel <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 WITH SAN <br />JOAQUIN COUNTY DEVELOPMENT TITLE. CHAPTER 9-1 111`5.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. j� ^ <br />JOB ADDRESS/OR APN+I /�./D AE/G ' I�O CITY S1614100 <br />1 PARCEL SIZE/AFRI( <br />OWNER'S NAME O -F RES8 yV PITONE R �"� <br />CONTRACTOR_ /%I L) S l ADDRESS /p (0 C)K ��C 9 LIC#' PHONE 120%- W A'10 <br />SUR CONTRACTOR C,/✓ �e I/y w ADDRESS / Jy (,� / o UCN��� PHONE <br />TYPE OF WELL/PUMP: <br />❑ NEW WELL <br />REPLACEMENT WELL MONITORING WELL I_ "� <br />❑ OTHER <br />❑ INSTALLATION <br />I❑ <br />❑ WELL SYSTEM REPAIR ❑ CROSS -CONNECT REPAIR <br />❑ VAPOR EXTRACTION WELL / <br />❑ New 11Reoalt <br />H.P. DEPTH PUMP SET FT. <br />FIRST WATER LEVEL <br />(TYPE OF PUMP( <br />❑ OUT -OF -SERVICE WELL ❑ GEOPHYSICAL WELL # <br />❑ <br />SOIL SOnING <br />R <br />❑ DESTRUCTION: <br />INTENDED USE <br />TYPE OF WELL <br />CONSTRUCTION SPECIFICATIONS <br />A <br />❑ INDUSTRIAL <br />❑ DOMESTICIPBIVATE <br />❑ OPEN BOTTOM DIA. OF WELL EXCAVATIOND 2C/ 1 i <br />1:1 GRAVEL PACK/81ZE�,��LTYPE VL <br />DIA. OF CONDUCTOR CASING <br />D <br />OF CASINO/STEEL/P�VC/ I <br />DIA. OF WELL CASINO � <br />0 <br />❑ PUBLIC /MUNICIPAL <br />11 DRIVEN <br />DEPTH 0 � <br />/ <br />OF GROUT SEAL (PlJO'P 11w,. <br />YO SPECIFICATION <br />R <br />IRRIGATIONIAG <br />❑ OTHER <br />GROUT SEAL INSTALLED BY�ifV <br />�Ce GROUT BRAND NAME <br />E <br />/❑ <br />L� MONITORING <br />GROUT SEAL PUMPED: ❑ Yea ,,LLf�ff�t N. CONCRETE PEDESTAL VY- []No <br />ATH <br />BY DRILLER: <br />S <br />APPROX. DEP <br />�:� <br />LOCKING CHESTER BOX/STOVE PIPE <br />#OJ�j/ <br />S <br />PROPOSED CONSTRUCTIONRIPoLLING <br />METHOD: <br />MUD ROTARY AIR ROTARY AUGER J <br />CARLE OTHER <br />1 HEBEBV 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 WORK FOR WHICH <br />THIS PERMIT IS ISSUED, 1 SHAI L NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRINO On SUBCONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: ' 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PEnSONB SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CALIFORN=T��A HOURS IN ADVANCE FOR ALL REQUIRED INSPECT <br />IO <br />NS <br />AT <br />12091469-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Slgned X Tltle ��/ <br />PLOT PLAN (Draw to Bcelel Bcelw ' to 0. <br />1. NAMES OF STRFFT8 OR ROADS NEAREST TO On BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED \ <br />2. OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DInECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />3. DIMENSIONED OUTLINES AND LOCATION OF ALL EX19TINO AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE Ht/NDnED FIFTY FT. <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AB PATIOS, DRIVEWAYS, AND WALKS. ON THE P'ROP'ERTY On ADJOINING PROPERTY. <br />APnlicwtlon Acewotwd By <br />GroU IrnpeEllen By <br />bnelrtrcllon Irnnerllon Sy <br />Commer.h: �� <br />D <br />ACCOUNTING ONLY: AID# <br />DEPARTMENT USE ONLY <br />Date Pump Irnpecllon Sy_ <br />Z <br />FAC# <br />Date �O'// L / A ­ <br />Pub. <br />Date <br />T2 <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED CIIECK#ICABH <br />RECEIVED BY DATE IT/SERVICE REQUEST N INVOICE <br />Pub. Health Serv. - Enviro. 173 (1/97) <br />