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....... ....... • • <br />.... • • • <br />APPLICATI-ON 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 />S (00 rHiL) <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete in Triplicate) <br />APPtICAION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTAU. THE WOW DESCRIBED. THIS APPLICATION IS MADE IN COMPLJANCE WITH SAN <br />JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1 1 1 5.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR APNS /I/0 E 11; 11, %Ai g CITY Locke -re p-ci PARCEL SIZVAPNS / 9 -ô 76 - a 1 <br />OWNER'S NAME -7-/ /if n e PIA/ ADDRESS PO, eaX cQ ii i-1 147 Pelee UM 9312VelioNE, ,206-...2g5-07q0D <br />CONTRACTOR 0 15rfer C, ADDRESS /73 - 3 I/11 LJCS PHONE I/ 7/‘ - 4/3-4- ti-113,1 <br />SUB CONTRACTOR e Ofr I ,,\1 fri ADDRESS ° r Box €3 g931 RAlc . 64.v.oc cs # qz,NE IV& gISP7-755.8 Px 1,":1R ) ca. <br />TYPE OF OF VVELUPUMP: ;a NEW WELL <br />0 INSTALLATION <br />0 Now 0 Repair <br />(TYPE OF PUMP) <br />0 DESTRUCTION: <br />REPLACEMENT WELL <br />WELL SYSTEM REPAIR <br />H.P. <br />OUT-OF-SERVICE WELL <br />Ai MONITORING WELL I/ 6 ,, 7 , OTHER <br />0 VAPOR EXTRACTION WELLS <br />FIRST WATER LEVEL <br />SOIL BORING <br />CROSS-CONNECT REPAIR <br />DEPTH PUMP SET FT. <br />GEOPHYSICAL WELLS <br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br />INDUSTRIAL 0 OPEN BOTTOM DIA. OF WELL EXCAVATION e- <br />DOMESTIC/PRIVATE 0 GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC PVC- / s cH i/c) - 0 PUBUC/MUNICIPAL 0 DRIVEN DEPTH OF GROUT SEAL o 6c ed- <br />IRRIGATION/AG 0 OTHER GROUT SEAL INSTALLED BY dr 1A-e'-ir <br />IS MONITOFUNG GROUT SEAL PUMPED: jaYsis 0 No CONCRETE PEDESTAL BY DRILLER: 0Y.. No <br />APPROX. DEPTH / 0 c -reel+ LOCKING CHESTER BOX/STOVE PIPE <br />PROPOSED CONSTRUCTION/DRIWNG METHOD: MUD ROTARY AIR ROTARY AUGER ./K CABLE OTHER <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATION AND THAT THE VVOW 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 WORK FOR WHICH <br />THIS PERMIT 18 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 18 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 0•I MIS-3423. C MPLETE DRAWING AT LOWER AREA PROVIDED. <br />Blared X <br /> <br />7074/ Title Date 30 <br />PLOT PLAN (Draw to Sago) Scale <br />I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, <br />OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. <br />DIMENSIONED OUTUNES AND LOCATION OF ALL EXISTING AND PROPOSED <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. <br />" t o <br />LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />$eo., ffib4-1.0-4kut_e__ <br />fd-ix4/Le- A <br />... <br />... <br />A <br />DIA. OF CONDUCTOR CASING N <br />DIA. OF WELL CASING ci:9. NC 14 <br />,F <br />D <br />SPECIFICATION <br />GROUT BRAND NAME Ve0-f- ceA-teA+ <br />Application Accepted By <br /> <br />DEPARTMENT USE ONLY <br />Data -C/6 Ar ea <br /> <br />Dot/ 671„ <br /> <br />Grout Inspection Inspection By Pump Inspection By <br /> <br />Dots <br /> <br />Destruction Inspection By <br /> Date <br />CommentEr <br /> <br />ACCOUNTING ONLY: AIDS <br /> <br />FA CI <br />PE CODES FEE INFO AMOUNT REMITTED CHEQ19il6ASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBEFI INVOICE <br />'?-T 7 k:.-r:e--