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illIPPLICATION FOR WELL/PUMP PERM <br />SAM, AOUIN COUNTY PUBLIC HEALTH SEOCES <br />ENVIRONMENTAL HEALTH DIVISION <br />304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br />(209) 468-3420 <br />NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete In Triplimn) <br />APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOFIK DESCRIBED THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />JOAOUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1 1 1 5.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />AST TENTH STREET JOB ADDRESS/OR APNi 5 0 3 E ciry TRACy PARCEL SIZE/APNIF 235- 1 "• 13 <br />OWNER'S NAME C ovivl-Nr OF SAN ToAClui ADDRESS 1.22_ E. wEBER AvE„ 6" FLOOR PHONE 00.0 9) 403 - 910 <br />SToCkroNl i CA 9 5 2.0-L_ CONTRACTOR FISCH ENVIRONMENTAL ADDRESS 399 SHEpo's pLAC.E uci C-51 PHONE 0(109)11 2-3510 <br /> <br />vALLEy sloqiucr s, CA ttG8 35 6 5 SUB CONTRACTOR ADDRESS 5 1 2. Lie/ PHONE A' <br />TYPE OF WELUPUMP: 0 NEW WELL <br /> <br />O REPLACEMENT WELL <br /> O MONITORING WELL <br /> <br />El OTHER GEOPI1,05E <br />0 INSTALLATION <br /> 0 WELL SYSTEM REPAIR <br /> <br />O CROSS-CONNECT REPAIR <br /> 0 VAPOR EXTRACTION WILE S J <br />(TYPE OF PUMP) <br /> 0 New 0 Repel, H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0 <br />OUT-OF-SERVICE WELL El GEOPHYSICAL WELL <br /> O SOIL BORING <br />El DESTRUCTION: <br />INTENDED USE TYPE OF WELL <br />El INDUSTRIAL 0 OPEN BOTTOM <br />Cl DOMESTIC/PRIVATE 0 GRAVEL PACK/SIZE <br />El PUBLIC/MUNICIPAL 0 DRIVEN <br />0 IRRIGATION/AG 0 OTHER <br />El MONITORING <br />APPROX. DEPTH 2 0 F T. <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF WELL EXCAVATION <br /> 2.- IN, DIA. OF CONDUCTOR CASING <br />TYPE OF CASINO/STEEL/PVC N A <br />DIA. OF WELL CASING <br />DEPTH OF GROUT SEAL TOT A L D EPTH SPECIFICATION <br />GROUT SEAL INSTALLED BY CONTRACTOR <br />GROUT BRAND NAME <br />NA <br />NA <br />NA <br />A <br />5 <br />GROUT SEAL PUMPED: III Yea 0 No CONCRETE PEDESTAL BY DRILLER: 0 Y.. S No <br />LOCKING CHESTER BOX/STOVE PIPE N A <br />PROPOSED CONSTRUCTION/DRILUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER GEO P IO BE <br />SOIL AND GROVNDWATER '3-NAB 5AMPLINCr I SAME- DAY ABANDONMENT <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE VVOFK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, Si ATE 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 VVORK FOR WHICH <br />TIIIS PERMIT IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATOR 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 APPUCANT MUST CALL 24 WILMS IN ADVANCE FOR All. REQUIRED INSPECTIONS AT (2011) 41111-1423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Slened X Tit,. CONSULT/4NT / A cr N T Date 10 1Z 9 91 <br /> <br />ToSEPli kAMAG-E PLOT PLAN lOraw to Seek., Seale •to <br />1. NAMES OF STREETS on ROADS NEAREST TO on BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />7. OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />1. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />STRUCTURES, INC1UDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WAU(S. ON THE PROPERTY on ADJOINING PROPERTY. <br />S E AT T A CHED <br /> <br />SI T <br /> <br />A <br />.. . <br />... <br />......... • <br />.. . <br />Application Aeoerpted By <br />Grout Ineperetlen By <br />DEPARTMENT USE ONLY <br />Date Pump Inepeollon By <br />Date Area <br />Delta <br />0.4.stftmtlan InspoctIon By <br />Commeut•• t; tlifin 7 - ig <br />Date <br />I ACCOUNTING ONLY: AIDS FAC0 <br />PE CODES FEE INFO AMOUNT REMITTED CHECK/MASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />1,5 9 IC 3- , /114-i4F -71;____----- <br />r' <br />Pub. Health Serv. Enviro. 173 (1/97)