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APPLICATION FOR WELLIPUMP PERMIT
<br />*� SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES
<br />ENVIRONMENTAL HEALTH DIVISION
<br />P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201.388
<br />(209) 469.3420
<br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED
<br />(Complsts In TripUcsts)
<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 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION.
<br />W626- JOB ADDRESS/On APN# 626-dL �41 �Njr,�,,(,�OI�,dO CIT-11-A-Aejc V n PARCEL
<br />SIZE/APNR �, 9`acreS(��n
<br />OWNER'S NAME n QASA%o.d.�il��10 tet{' ADDRESS 30� N, t . 012 � ,(�y�/�� /Ai�PHONE f 1 q3'f 6 JS_3
<br />CONTRACTOR J�eG�rGrk, �(•P1�,�1 �1 ADDRESS_«3�5 �%/9%{/•lm% )ICI UCf 5'1 a6OPHONEfob`1-465-871oL
<br />SUB CONTRACTOR ADDRESS (Z' 5. -AO
<br />UCf}} __,, PHONE #
<br />TYPE OF WELLIPUMP; El NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL # 19 OTHER OWN VA GW 1- G W3
<br />❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS -CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I ,/
<br />❑
<br />(TYPE OF PUMP) New 11RepairH.P. DEPTH PUMP SET FT. FIRST WATER LEVEL Q Q O
<br />❑ OUT-Gr'BERVICE WELL ❑ GEOPHYSICAL WELL # SOIL BORING
<br />❑
<br />DESTRUCTION:
<br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS
<br />❑ INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASINO O�
<br />❑
<br />DOMESTIC/PRIVATE ❑ GRAVEL PACKISIZE TYPE OF CASINOISTEEUPVC DIA. OF WELL CASING D
<br />❑ PUBLIC/MUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL SPECIFICATION
<br />R
<br />9
<br />IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E
<br />❑ MONITORING GROUT SEAL PUMPED: ❑ Vee [IN. CONCRETE PEDESTAL BY DRILLER: ❑ Yea [IN.
<br />S
<br />APPROX. DEPTH LOCKING CHESTER BOX/STOVE PIPE
<br />PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER
<br />I HMRY 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 AN
<br />nEOU 9 OF SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: •1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHIC
<br />THI RMIT 18188UE , 181RALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUB -CONTRACTING SIGNATURE CERTIFIE�
<br />TH FOLLOWING: ' 1 ERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS O
<br />CAL RICA.• THEA CANT MUST ALL 24 HOUR IN ANCE FOR ALL REQUIRED INSPEF, T10N8 AT "1409-3422. COMPLETE DRAWING AT LOWER AREA PRO72-
<br />ED.
<br />Stpned X Tltls '�L_A/I a44 �Dats
<br />PLOT PLAN ID,ow to Seale) Scala • to
<br />1. NAMES OF STREETS OR ROADS NEARER T OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED
<br />2. OUTLINE OF THE PROPERTY, GIVING DI E SIGNS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS.
<br />3. DIMENSIONED OUTUNFS AND LOCATI 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 AnJD1N1Nn PRnpp RTY
<br />Applicatlon Ac—pled I
<br />Grout Impaction By
<br />Destruction Impelonn L
<br />DEPARTMENT UBE ONLY
<br />Date Pump Inspection
<br />Date —�'F A,”
<br />Data
<br />ACCOUNTING ONLY:
<br />AID#
<br />CHANNEL ST
<br />I_ ARCO
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<br />PE CODER FEE INFO AMOUNT REMITTED
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<br />t�RAtIYt
<br />RECEIVED BY DATE
<br />PERMIT/SERVICE REQUEST NUMBER INVOICE
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<br />SAMPLE LOCATION MAP
<br />FIGURES -1
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<br />Weber Block (Area 9)
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<br />Stockton, San Joaquin County, California
<br />MRD/W BRBLR SMPLD 1)%11
<br />I
<br />Applicatlon Ac—pled I
<br />Grout Impaction By
<br />Destruction Impelonn L
<br />DEPARTMENT UBE ONLY
<br />Date Pump Inspection
<br />Date —�'F A,”
<br />Data
<br />ACCOUNTING ONLY:
<br />AID#
<br />FAC!
<br />PE CODER FEE INFO AMOUNT REMITTED
<br />CHECK#/CAASII
<br />RECEIVED BY DATE
<br />PERMIT/SERVICE REQUEST NUMBER INVOICE
<br />7+ Ts-�N F� (Eat`
<br />V
<br />Pub. Health Serv. - Enviro. 173 (3/96)
<br />
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