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NEW WELL <br />INSTALLATION <br />0 New 0 Repair <br />TYPE OF WELIJPUMP: <br />IRRIGATION/AG <br />MONITORING <br />INTENDED USE <br />INDUSTRIAL <br />DOMESTIC/PRIVATE <br />PUBLIC/MUNICIPAL <br />0 <br />LOCKING CHESTER BOX/STOVE PIPE <br /> <br />AIR ROTARY AUGER CABLE OTHER 44-, 41v ,, <br />APPLICATION FOR WELLIPUMP PERMIT <br />PAYMENT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />RECEIVED ENVIRONMENTAL HEALTH DIVISION <br />P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201488 <br />MA"( 0 8 19q6 1209) 468-3420 <br />spm jo,.,.AttN <br /> <br />IN <br />ppucAETINVI <br />PUBLIC HEALTH <br />RO H <br />;1 ;," NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />A <br /> <br /> RE M E SA JOAO COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPIJANCE WITH SAN <br />No MliLE TO <br />E THE <br />L N OIVIJ1uU IN <br />(Complete in Triplicate) <br /> <br />IS H <br />BY <br />JOAQUIN COUNTY DEVELOPMENT / TgLE CHAPTER 9-1 1 1 5.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />? <br />JOB ADDRESS/OR APN* 1-").7raiii" <br />OWNER'S NAME /34? ii 4 ; ,44 J, .7 <br />CONTRACTOR Ci -PeiVe.) / C rsic. <br />- 1: <br />ADDRESS lei ge-..9,4" c73-',a--,/ PHONE // <br />ADDRESS 7'7/ X)/ Lic#4)6,. -SPHONE <br />OTHER <br />VAPOR EXTRACTION WELL * <br />FIRST WATER LEVEL <br />12K-011 BORING <br />0 DESTRUCTION: <br /> <br />DIA. OF WELL EXCAVATION <br />TYPE OF CASING/STEEUPVC <br />DEPTH OF GROUT SEAL <br />GROUT SEAL INSTALLED BY <br />GROUT SEAL PUMPED: 0 Yee <br />DIA. OF CONDUCTOR CASING <br />DIA. OF WELL CASING <br />SPECIFICATION <br />GROUT BRAND NAME <br />arJo CONCRETE PEDESTAL BY DRILLER: 0 Yee 0 No <br />TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br />Pri <br />,t1.1 <br />0 OPEN BOTTOM <br />0 GRAVEL PACK/SIZE <br />0 DRIVEN <br />0 OTHER 3t2,/ 471 <br />3 <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 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, 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 OF <br />CALIFORNIA." TH APPUCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12051468-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Signed X Title eek; /6;,- /5 / Date s/7 <br />.5ce 4 <br />.47 r <br />eFT /5 <br />5v-rra <br /> 5 4t <br />. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />. OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED B. 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 ADJOINING PROPERTY. <br />DEPARTMENT USE ONLY <br />D at el444:/kii- Pump Inspection By <br />Area LI q 7 <br />Date <br />Application Accepted By <br />Grout Inspection By (4-k-A--- <br />Destruction Inspection By <br />Comments: - <br />ACCOUNTING ONLY: AIDS FAC# .- <br />PE CODES FEE INFO AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />Z;(7 /6(-, 4.1.-/e_ ts ///,,-.E 43 077-it/ <br />--„, <br />SeN00092--- <br />Date <br />Date <br />PLOT PLAN (Draw to Scale) Scale I " to <br />SUB CONTRACTOR ADDRESS LIG* PHONE if <br />APPROX. DEPTH <br />PROPOSED CONSTRUCTION/DRILUNG METHOD: MUD ROTARY <br />V77 <br />_ ik__-I_ II <br />PARCEL SIZE/APN# -61,2 <br />REPLACEMENT WELL 0 MONITORING WELL I <br />WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR <br />H.P. DEPTH PUMP SET FT. <br />OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL I <br />(TYPE OF PUMP) <br />AD0- ) <br />Fts) <br />s <br />_ <br />CITY