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J UL <br />APPLICATION FOR WELLIPUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201-388 <br />(209) 468-3420 <br />SUB CONTRACTOR ADDRESS LIC# PHONE # <br />0 SOIL BORING <br />(TYPE OF PUMP) <br />0 OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL # <br />DIA. OF CONDUCTOR CASING <br />CONSTRUCTION SPECIFICATIONS i <br />DIA. OF WELL EXCAVATION 111(261,1 v <br />" to <br />4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />B. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />PLOT PLAN (Draw to Scala) Scale <br />NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. <br />OUTUNE OF THE PROPERTY, GIVING 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 />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/OR INSTALL THE WORK DESCRIBED. THIS APPeLfilkfAiS ANCE WITH SAN <br />JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL 11 <br />JOB ADDRESS/OR APN# 11196 Akrih CI ay-4Jc 5-i-ter-+- CITY Stric k 4-e r. PARCEL SIZE/APN# <br />OWNER'S NAME flfg (it+, c...rekpcm4).. ADDRESS VI (JAS----S.L )at ek /MI (.(4 riiphe iL ot-pHoNE # <br />CONTRACTOR Et )06,14 wk." /2-1111,9) ADDRESS P Box 3 3 k uc#SN'i CY( PHONE #7t-- --5/266 <br />TYPE OF WELL/PUMP: ,NEW WELL 0 REPLACEMENT WELL 0 MONITORING WELL # igt OTHER Alf soar 5 2 ; J )1' 0 INSTALLATION 0 WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR g VAPOR EXTRACTION WELL # Vu!'!), (1w dr• <br />0 New 0 Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0 <br />1995 <br />0 DESTRUCTION: <br />INTENDED USE TYPE OF WELL <br />INDUSTRIAL 0 OPEN BOTTOM <br />DOMESTIC/PRIVATE 0 GRAVEL PACK/SIZE <br />PUBLIC/MUNICIPAL 0 DRIVEN <br />IRRIGATION/AG 0 OTHER <br />"14 MONITORING <br />APPROX. DEPTH -35 <br />PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER X CABLE OTHER <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND2) <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 WOW FOR WHICH <br />THIS PERMIT IS ISSUED, I SHALL 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 WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS 0 <br />CALIFORNIA." THE APPUCANT MUST C 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12091 488-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />.469,6,t rt4 Title 6 eLis f Date 7- 2 'I f (;) <br />Signed X <br />DEPARTMENT USE ONLY <br /> Date Area <br />Date <br />V <br />Date ( Pump Inspection By <br />5-2 r 3 <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />Comments: <br />`772 <br />ACCOUNTING ONLY: ONLY: AIDE FACE <br />PE CODES FEE INFO AMOUNT REMITTED CHECKJf/CASH RECEIVED BY DA9. PERMIT/SERVICE REQUEST NUMBER INVOICE <br />350 I ',?..)ci '-- :-/ o3:..2.1 ---P1 <br />S 6 O 0 6 li 3 <br />TYPE OF CASING/STEEL/PVC <br />DEPTH OF GROUT SEAL <br />GROUT SEAL INSTALLED BY <br />GROUT SEAL PUMPED: 0 Yew <br />DIA. OF WELL CASING 4".01C1 Li 1 <br />SPECIFICATION <br />GROUT BRAND NAME Air-Ha nd <br />0 No CONCRETE PEDESTAL BY DRILLFR: 0 Yee 0 No <br />LOCKING CHESTER BOX/STOVE PIPE S