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APPLICATION FOR WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SE, ES <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 />CONTRACTOR (AJP.A/NAYAker 6-v/Aiej PrIC.n.. <br />PHONE # 1:411%)‘/Z "*. S./ 49C- <br />SUB CONTRACTOR Al/k_C-.4 . RAV NYAAKINAA4Zart ADDRESS p.63-,), -zq 9.6,.....c...ko uc, cps ifq-4, PHONE <br />OWNER'S NAME Si .1-e/ilk._ IR...3i Z ADDRESS Lit-Kt I gAil Dvv.i.v —. ftrry ge(i -pz..IPHONE S <br />JOB ADDRESS/OR APN$ q q 61, 1 (Al ' Oki V. W4...11- Rfri 0-6( crre ' (r( C.A1 PARCEL SIZE/APN. <br />JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <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 />(Complete in Triplicate) <br />ADDRESS2';-' Zej —111 4.04- ST2 44 1,6*, tabe-.10 <br />NEW WELL <br />INSTALLATION <br />El New CI Repair <br />TYPE OF WELL/PUMP: <br />(TYPE OF PUMP) <br />0 DESTRUCTION: <br />INTENDED USE <br />INDUSTRIAL <br />DOMESTIC/PRIVATE <br />El PUBLIC/MUNICIPAL <br />IRRIGATION/AG <br />ca MONITORING <br />APPROX. DEPTH <br />REPLACEMENT WELL <br /> O MONITORING WELL <br />WELL SYSTEM REPAIR <br /> O CROSS-CONNECT REPAIR <br />H.P. DEPTH PUMP SET FT. <br />OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL <br />OTHER <br />13 VAPOR EXTRACTION WELLS VVI <br />FIRST WATER LEVEL <br />SOIL BORING <br />DIA. OF CONDUCTOR CASING <br />DIA. OF WELL CASING <br />SPECIFICATION <br />GROUT BRAND NAME <br />CONCRETE PEDESTAL BY DFUU_ER: El Yes 0 No <br />TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br />El OPEN BOTTOM <br />DIA. OF WELL EXCAVATION <br /> IC ') <br />0FtltVet-PACK/SIZE TYPE OF CASING/STEEL/PVC PVC, Ri-e tc <br />0 DRIVEN DEPTH OF GROUT SEAL <br />0 OTHER GROUT SEAL INSTALLED BY 91e. <br />GROUT SEAL PUMPED: 0 Yes lallo <br />W.A./STOVE PIPE <br />A <br />LI <br />PROPOSED CONSTRUCTION/DR1LUNG METHOD: MUD ROTARY AIR ROTARY AUGER ;),( CABLE OTHER <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE VVOFIK 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 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 WOW FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CALIFORNIA." THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12081 4684423. COMPLETE DRAWING AT LOWER AREA PROViDED. <br />lro--rin,.." ("AA Title Pr CVYt ..V-40 Date <br />PLOT PLAN (Draw to Scale) Scale - to Lto <br />OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. <br />1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. <br />4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED—, <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED <br />5. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY F17--- <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br />Signed X <br />41) otim • te <br /> tri <br />1• A.1 <br />Nitt4-3 01) <br /> Cr? <br />aw.4111 <br />viol. CD <br />Application Accepted By <br />Grout Inspection By <br />DEPARTMENT USE ONLY <br />Date 1/44 Pump Inspection By <br />Date IILTT Area <br />Date <br />Destruction Inspection By <br />Date <br />Comments: <br />ACCOUNTING ONLY: AIDS EAU/ <br />PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />---, .---- <br />3c•-i <br />7.53 .7 ,„,/,.) plveiT 511. q / 0 ..•` -7 (., i 4-- <br />"-----.--S1?--. <br />------,,, <br />C C I. <br />„ .. , ._ ...._,....... , . _ . ,--..