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APPLICATION FOR WELL/PUMP PERMIT <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 />(Complete IR Trip Rents) <br />APPLICATION 19 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 WrTH SAN <br />JOAOUIN COUNTY DEVELOPMENTTITLE,TITLE, CHAPTER 9-1115.3 AND TI4E STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESWOR/APN# i U ,0 � �,4+Yi'LcK-4- vT{/a tt+ CITY Lo7d 1 PARCEL SIZE/APNI�I�.rd <br />OWNER'S NAME <br />,�j6 .."Otlkt��jJ�{�/ �2�!=IC�Ib'l�rLl`}N4Y Ikt IL Iiy ADORESB F- 0, I1L ). i jJjCj 1s/�J L,L L f� 11PHONE# <br />CONTRACTOR /191. VOVC'CC.i (� tC �N VLI t"p 11 W1,t41 �'Q'� „� C - ADDRESS 400 7 tV W, 4Cr1 �' 144 UC# 10 .14 PHONE # �IL� <br />SUB CONTRACTOR ADDRESS UC# PHONE # <br />TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL # ❑ OTHER <br />❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS -CONNECT REPAIR ❑ VAPOR EXTRACTION WELL / J <br />❑ New ❑ Repolt H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br />(TYPE OF PVMPI E 11ryq�� .f, <br />❑ OUT-OF-SERVICWELL GEOPHYSICAL WELL # Q& SOIL BORING 4 92 1 B <br />❑ DESTRUCTION <br />INTENDED USE <br />TYPE OF WELL <br />CONSTRUCTION SPECIFICATIONS <br />71 <br />A <br />❑ INDUSTRIAL <br />❑ OPEN BOTTOM <br />DIA. OF WELL EXCAVATION <br />_ <br />DIA. OF CONDUCTOR CASINO <br />0 <br />❑ OOMESTK:B'RIVATE <br />EIGRAVEL PACK/SIZE <br />TYPE OF CASINO/STEEVPVC <br />DIA. OF WELL CASINO <br />❑ PUBLIC /MUNICIPAL <br />IRDRIVEN <br />T <br />DEPTH OF GROUT SEAL 1 _ .n <br />SPECIFICATION <br />B <br />❑ IRRIGATION/AO <br />❑ OTHER <br />GROUT SEAL INSTALLED BY I rA i+41 tN I Q <br />GROUT BRAND NAME P0.0't �� �� C+NLI{L r <br />E <br />MONITORING <br />GROUT SEAL PUMPED: ❑ Y- r$ No <br />CONCRETE PEDESTAL BY DRILLER: ❑ Yee ®No <br />5 VN <br />` <br />APPROX. DEPTH J / <br />LOCKING CHE9TER BOX/STOVE PIPE <br />5 <br />PROPOSED CONSTRUCTION/DIIILLINO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER'+ (V' JZ Vii4 Y h <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 THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIER THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH <br />THIS PERMIT 19 ISSUED, 1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB -CONTRACTING SIGNATURE CERTIFIER <br />THE FOLLOWING: ' 1 CERTIFY THAT IN TILE 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 CC�A/LLLUR <br />24 HOS IN ADVANCE FOR ALL REOUIRED INSPECgTIONS AT 12091 PROVIDED. <br />400-1422. COMPLETE DRAWING AT LOWER AREA PVIDED. rJ <br />819—d X ,J /l/'�r {1!E'1 Tltl. � 1* - <br />PLOT PLAN IOrt.,v to Sodel Sade - to <br />1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL BY97EM OR PROPOSED <br />2. OUTLINE OF THE PROPERTY, GrVM1O DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />3. DIMENSIONED OUTLMFB AND LOCATION Of ALL EXISTMO AND PROPOSED S. LOCATION OF WELLS WITHIN RADIU8 OF ONE HUNDRED FIFTY FT. <br />STRUCTUREB, INCLUDING COVERED AREAS SUCH A$ PATIOS, DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br />Appkstlon Aaoepted By 'r �•,,✓�`� <br />O—A IMP -11— By <br />De W.00n I—F-00n By <br />Commer w S 13, <br />DEPAATMENT USE ONLY <br />0 '� � Pump I—poett— By <br />Owe A, <br />Date <br />ACCOUNTING ONLY: <br />AID# <br />TAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED CHECZ!�*CASH <br />RECEIVED BY <br />DATE PERMIT/SERVICE REQUEST NUMBER <br />INVOICE <br />2c <br />Pub Health Serv. - Enviro. 173 (1/97) <br />