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APPLICATION FOR WELLIPUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201-388 <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/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 />JOB ADDRESS/OR APN# 11 0 0 0 5. ,4h iyg <br />ctry /- c ke PARCEL SIZE/APN# 0 9- 6 76 — a I <br />c 0/4 PIA/r <br />gce,k 1E-A c, <br />I ; <br />ADDRESS eo, ea x seer/ t ,t,v4 ?savpHoNE # .201)-4.2gs-07qm <br />ADDRESS I 73 / - 3 74 Pf-- IJC# PHONE # 7/6 - gS-4-q33:1 <br />ADDRESS ,Box ,93I Ran t 4. 64Aucs c5 7 # eV" 44ToNE ,s-K5,2-75-58 <br />OWNER'S NAME <br />CONTRACTOR <br />SUB CONTRACTOR <br />TYPE OF VVELUPUMP: <br />(TYPE OF PUMP) <br />0 DESTRUCTION: <br />Pi NEW WELL <br />0 INSTALLATION <br />0 New 0 Repair <br />REPLACEMENT WELL <br />WELL SYSTEM REPAIR <br />H.P. <br />OUT-OF-SERVICE WELL <br />%MONITORING WELL # 5 g /0 <br />CROSS-CONNECT REPAIR <br />DEPTH PUMP SET FT. <br />GEOPHYSICAL WELL S <br />OTHER <br />VAPOR EXTRACTION WELL # <br />FIRST WATER LEVEL <br />SOIL BORING <br />TYPE OF WELL <br />OPEN BOTTOM <br />0 GRAVEL PACK/SIZE <br />0 DRIVEN <br />0 OTHER <br />/00 -reel+ <br />INTENDED USE <br />INDUSTRIAL <br />DOMESTIC/PRIVATE <br />PUBLIC/MUNICIPAL <br />IRRIGATION/AG <br />Pr MONITORING <br />APPROX. DEPTH <br />CONSTRUCTION SPECIFICATIONS <br />NA. OF WELL EXCAVATION <br />TYPE OF CASING/STEEL/PVC P v / scH <br /> <br />o- " DEPTH OF GROUT SEAL ifs Fe e..+" <br />GROUT SEAL INSTALLED BY Cir Ott <br />GROUT SEAL PUMPED: jErYee 0 No <br />LOCKING CHESTER BOX/STOVE PIPE <br />--1-- <br />......Q A <br />DIA. OF CONDUCTOR CASING Nfr ,.....-- D <br />DIA. OF WELL CASINO e9. 1 N C 14 ( .p D <br />SPECIFICATION <br />...oz <br />R <br /> <br />GROUT BRAND NAME ce ,s-te4+ <br />CONCRETE PEDESTAL BY DRILLER: 0Y.. No COS <br />- iirch( <br />PROPOSED CONSTRUCTION/DRILUNG METHOD: MUD ROTARY AIR ROTARY AUGER .0K. CABLE <br />OTHER <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE VVORK 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: 1 CERTIFY THAT IN THE PERFORMANCE OF THE WOFVC. 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.* THE APPUCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT I 4011-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Signed X 74#'24/ Title Date 1/— 3° — 96 <br />PLOT PLAN (Draw to Seale) Scale <br />NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. <br />OUTLINE 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 />to <br />4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br /> '4.1.1111014.1101.1., <br />DEPARTMENT USE ONLY <br />Application Accepted By Date 3/1 /vest— P <br />Grout inspection By Dote F ic, Pump Inspection By Date <br />Destruction Inspection By Date <br />Comments: <br />ACCOUNTING ONLY: AIDS . FAC# 3 .50. (-) I <br />PE CODES FEE INFO AMOUNT REMITTED CH9CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />il AC' <br />Fy <br />.....23 <br />07 t( t,Th f i,i L. <br />1, 1 ' ) i y f (x <br />Z I _ -----------__,\I