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APPLICATION FOR WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />.c &te /1/ ,i4): ENVIRONMENTAL HEALTH DIVISION <br />304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br />/ /)`- <br />(209)468.3420 <br />NON PERMIT EXPIRES 1 YEAR FROM DATE ISSUED N <br />(Complete In Triplients) <br />APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FO A PERMIT TO CONSTRUCT ANoron INSTALL THE WOW DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1 115.3 AND JIM STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />(7) 4 JOB ADDRESS/OFI i —7 - r 1/4""APN/ y -.k _ A ) 441.4.2_ co-y PARCEL SIZE/APNP 5,12-c4 Lu ‘f '1/4) 14/1 cun-i-e— 6 ,•-t. 4, L:11 OWNER'S NAME lAnDRES8 ?(Yr,>_, PHONE i <br />CONTRACTOR /fat, ADDRESS '1(.1Z.,:; <Ta (..)/ 'IS LIZ C I 1./.,Z2 2 PHONE I <br />SUB CONTRACTOR .S.C;-•4-4),),)5.21,1,-t= ADDRESS 5-V -FL.L t4UCI T?'?' L22 <br />Lo P <br />TYPE OF WELL/PUMP: IIKEIN WELL <br />0 INSTALLATION <br />El New 0 Repalr <br />ID REPLACEMENT WELL <br />0 WELL SYSTEM REPAIR <br />H.P. <br />Et....1[-AONITORING WELL I —7 <br />0 CROSS-CONNECT REPAIR <br />DEPTH PUMP SET FT <br />OTHER <br />VAPOR EXTRACTION WELL <br />FIRST WATER LEVEL <br />SOIL BORING <br />(TYPE OF PUMP) <br />0 OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL <br />El DESTRUCTION: <br />TYPE OF WELL <br />0 OPEN BOTTOM <br />lErGRAVEL PACK <br />0 DRIVEN <br />0 OTHER <br />INTENDED USE <br />INDUSTRIAL <br />0 DOMESTIC/PRIVATE <br />PUBLIC/MUNICIPAL <br />IRRIGATION/AG <br />'MONITORING <br />APPROX. DEPTH <br />CONSTRUCTION SPECIFICATIONS <br />g DIA. OF WELL EXCAVATION <br />TYPE OF CASINO/SIMI& <br />DEPTH OF GROUT SEAL Li, 7'1-rk.---. <br />GROUT SEAL INSTALLED BY I <br />GROUT SEAL SEAL PUMPED: 0 Yea D-No <br />LOCKING CHESTER BOX/STOVE PIPE <br />DIA. OF CONDUCTOR CASING <br />DIA. OF WELL CASINO <br />SPECIFICATION <br /> // <br />GROUT BRAND NAME .7&27-1/171\ <br />CONCRETE PEDESTAL BY DRILLER: 0 Y. 0 No <br />PROPOSED CONSTRUCTION/DRILUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE <br />OTHER <br />1 V1EREBY CERTIFY THAT I HAVE PREPARED THIS APFUCATION 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: 'I CERTIFY THAT IN THE PERFORMANCE OF THE VVOTE 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 VVORK FOR WHICH THIS PERMIT 18 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />Sloe. X <br />CALIFORNIA.' THE APPU1 NT MUST CALL 24 UR* IN ADVANCE FOP. AU, REQUIRED INSPECTIONS AT I20 1111 <br /> Title C:liV,CV/: 11-- Date ,-_ -- <br />/1 <br />‘j <br /> <br />4114-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />PLOT PLAN (Draw to Boole) Seale <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 />1. <br />LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM on PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />s <br />... <br />... <br />.. - <br />DEPARTMENT USE ONLY <br />ApplIcatIon Accepted By Dale Ar.G.0 I <br />Grote Impeellon By DaleV 2-1'1 <br /> <br />Pump Inspection BY Dela <br />Oemoretlen Impaction By <br />Contreere•: 5 <br />Date <br />0.1 L.P - to 7 016 S&tz 6 5r1P <br />ACCOUNTING ONLY: AIDS FACS <br />— <br />PE CODES FEE INFO AMOUNT REMITTED CHE‘S,k ASH RECEIVED BY DAT PERMIT/SERVICE REQUEST NUMBER INVOICE <br />_.., / bf`i <br />------.) <br />gr\bONS\60A <br />Pub. Health Serv. - Enviro. 173 (1/97)