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APPLICATION FOR WELL1PUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVILLo <br />ENVIRONMENTAL HEALTH DIVISION <br />P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201-388 <br />UM 468.3420 <br />NON-REFUNDARE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete In riplicetal <br />APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/0/1 INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />JOAOUIN COUNTY DEVELOPMENT TTTLE, CHAPTER 9-1 115.3 <br />AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. 7 AcizEs <br />JOB ADDRESS/OR APED/ 7 41 13 I ruAir?-.4.„' ,4C4P_Ativi6/4/-0 fe.,j clre Sret rtAi PARCEL SIZE/APNI/ I:, -7 7 - 3 0 - <br />OWNER'S NAME .gi-fe Li- 01 L ?aoiaoci_S CD, ADDRESS 0,Go OW Atzw --2 PHONES k9lU / 335--S-0 a 7 <br />CONTRACTOR CAin G2 lA -Etv CAW NN•c-t.i TEc / ADDRESS 270 s <br />SUB CONTRACTOR Gi(JE... Z1 LA- I /1/44.3-- -TE-c."7-2 <br />TYPE OF WELL/PUMP: <br />(TYPE OF PUMP) <br />0 DESTRUCTION. <br />NEW WELL <br />0 INSTALLATION <br />0 New 0 Renoir <br />0 REPLACEMENT WELL <br />WELL SYSTEM REPAIR <br />H.P. <br />OUT-orSERVICE WELL <br />MONIToniNo WELL # <br />ID CROSS-CONNECT REPAIR <br />DEPTH PUMP SET FT. <br />GEOPHYSICAL WELLS <br />OTHER <br />VAPOR EXTRACTION WELLS <br />FIRST WATER LEVEL <br />or SOIL nornno $64-, <br />1110NE 470 —la <br />AnnnEse 4// 24 es-7- 4bS7(I,-F-4,0NE ‘5,0 <br />UCK <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF WELL EXCAVATION <br />DIA. OF CONDUCTOR CASING <br />TYPE OF CASING/STFEUPVC <br />DIA. OF WELL CASINO <br />DEPTH OF GROUT SEAL <br />SPECIFICATION <br />GROUT SEAL INSTALLED BY GROUT BRAND NAME <br />GROUT SEAL PUMPED: 0 Yoe 0 No CONCRETE PEDESTAL BY DRILLER: 0 Yoe 0 No <br />LOCKING CHESTER BOX/STOVE PIPE <br /> AIR ROTARY 11=TFarre AUGER CABLE OTHER (1-60.X.1.13 E <br />INTENDED USE TYPE OF WELL <br />0 INDUSTRIAL <br /> o OPEN BOTTOM <br />DOMESTIC/PRIVATE <br /> 0 GRAVEL PACK/SIZE <br />PUBLIC/MUNICIPAL <br /> 0 DRIVEN <br />IRRIGATION/AG <br /> 0 OTHER <br />MONITORING <br />APPROX. DEPTH <br />PROPOSED CONSTRUCTION/0111LUNG METHOD: MUD ROTARY <br />A <br />0 <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND <br />REGULATIONS OF THE SAN JOAOUIN 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 MAIL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA. CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br />' <br />THE FOLLOWING: I EITTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS O <br />CALIFORN EHIPA ANT IN'e. ALL 24 HOURS IN ADVANCE FOR All REQUIRED INSPIECT101411 AT 12051 41111-3422. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Title ROL)e..C7— 6€ii s7 - <br />PLOT PLAN (Orme to Boole, Seale 1 Ev- - to Z.1/197 <br />I. NAMES OF STREETS OR ROADS NEAREST TO on 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 />Se -E A IM <br />Nr4r‘ C09 C4tel <br />... <br />... <br />... <br />ApplleotIon Accepted By <br />DEPARTMENT USE ONLY <br /> <br />Dote 1'1.3 / <br />Aro* <br />Grout Inspection By Dole Pump Inspection By <br />Dote <br />DeotrectIon Inspection By <br />Dote <br />Comments: <br />ACCOUNTING ONLY: AIDS FACE <br />PE CODES FEE INFO AMOUNT REMIT 1 ED CHECKS/CASH RECEIVED BY DATE PERMIT/SERVICE RECTUM NUMBER INVOICE S5 o 1 AID2-{ )1m19- 12_311 .5w0 1 H 3-1,V <br />Pub. Health Serv. - Enviro. 173 (3/96) <br />Slened X <br />Dote <br />LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM on 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.