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NPPLICATION FOR WELL/PUMP PERMI- <br />SAI AQUIN COUNTY PUBLIC HEALTH SEI -'ES <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/On INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9- 115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC <br />PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR APN!/ `�' FV 'ZvV��1!� CITY ,y <br />�-tI�`{y S1A Z�r`PAR�CCEz LO(S, I(Z( E/APNM 7-A,4, -y `' Z aOWNERIB NAMEADDRESS PQ- �y,y� PHONE R <br />ADDRESS I !HONE / CCONTRACTOR CON JL <br />•�/ 1 ` Z. 2 Z <br />SUBCONTRACTOR F,- ��-�1%J V�u�1.N1-c..� ADDRE68 tt'•.11��"a �'�'`� l K'� / �Z '.35 <br />UCu PHONE? <br />TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER <br />❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS -CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I <br />❑ New 11Repelr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br />HYPE OF PVMPI i <br />El OUT -OF -SERVICE WELL 11 GEOPHYSICAL WELL I SOIL SORING 3 � ,, ) Q B <br />❑ DESTRUCTION: <br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONSt A <br />El INDUSTRIAL OPEN ROT -TOM , <br />OM DIA. OF WELL EXCAVATIONy �. V� DIA. OF CONDUCTOR CASINGiV� �- D <br />ElR' <br />DOME9TICRIVATE ❑G&RAVEL PACKISIZE TYPE OF CASINO/STEEUPVC I V) DIA , OF WELL CASING � / D <br />❑ PUBLIC /MUNICIPAL �❑j.DRIVEN DEPTH OF GROUT SEAL 3C SPECIFICATION 'V )• B <br />ElIRRIGATIONIAG 151 OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME i, �. � Vt'1''t E <br />BY <br />❑ MONITORING (� GROUT SEAL PUMPED: U Y- ❑ ee N <br />No CONCRETE PEDESTAL BY DRILLER: ❑ Yo 5 <br />APPROX. DEPTH L••t -� �-4'1\ �3 C` LOCKING CHESTER BOX/STOVE PIPE g <br />PROPOSED CONATRUCTIONIDRIL NO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER_je,11" <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 T14E RAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br />THIS PERMIT IS ISSUED, 1 814AI.L NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR BUB-CONTRACTINO SIGNATURE CERTIFIES <br />THE FOLLOWING: ' I CERTIFY THAT IN THE PERFORMANCE OF THE WOW( FOR WITICH THIS PERMIT 18 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WOnKMAN'@ COMPENSATION LAWS OF <br />CALIFORNIA.' THE APPLICANT MUST CALL 124 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION@ AT 120014n6600-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Slpned X_ _ _ y �y-� TItI. b�-- Det. <br />PLOT PLAN (Drew to 9.0ol Scale ' 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 SYSTFMB. <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 A8 PATIOS, DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br />Appll..0w, Aceeplod <br />Grout In pectlon By <br />bnehuetlen Inenectlen <br />C- ­W <br />DEPARTMENT USE ONLY <br />Det. Pump Inepeetlon <br />w LJ Q <br />W <br />U ~ Z Z <br />Z V Q O <br />Q O :2 u- <br />:2 Z W o, re J <br />i o� a -,00< <br />W W U o L U <br />� w � <br />a Z a Lj <br />w O Z <br />V) n O <br />W � Y J H <br />N W U W Y <br />O V) U <br />o vN LJ O <br />O E <br />c <br />0 <br />Z <br />K <br />0 <br />O <br />rn <br />W <br />0 <br />a- <br />0 <br />a <br />N <br />OHe <br />ACCOUNTING ONLY: AIDA <br />FACT <br />PE CODES <br />FEE INFO <br />LINT REMITTED CHECKNICA911 <br />RECEIVED BY <br />DATE PERMIT/@EAVICE REQUEST NUMBER <br />INVOICE <br />/ i <br />Pub. Health Serv. - Enviro. 173 (1/97) <br />