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APPLICATION 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 />PARCEL SIZE/APN#
<br />OWNER'S NAME rilt.irlAsee2;70sOrjelnir‘r
<br />/61AZoi 64,-ez,-.. 6,1 kz.)
<br />
<br />ADDRESS rr 1.4/eit PHONE # 1777-77/.3
<br />CONTRACTOR F/4/01r ADDRESS/K4E-h 'nit Li 64 9.4" jJcs
<br />7.3; , ,ae rtz )
<br />ia eY?LI C e- S-7
<br />PHONE 3r- 3770
<br />SUB CONTRACTOR U/Ifit ADDRESSna S-r.arr-410 cet• a4-1. 4/17S-7fax# S1-9? 79 pii049"163,- 7.2.n
<br />TYPE OF WELL/PUMP: 0 NEW WELL
<br />
<br />o REPLACEMENT WELL
<br /> O MONITORING WELL 5 0 OTHER
<br />0 INSTALLATION
<br /> O WELL SYSTEM REPAIR
<br /> O CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELL #
<br />0 New El Repair
<br />H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL
<br />(TYPE OF PUMP)
<br />76 DESTRUCTION: 6?-61-4-4-(34,- $1,42i,,,46.1:1 6,1,4, 7 4,41 14./ -Zel 4,;// 4.4. ace„,,://1,4 ,1 ic 4 id z/1:774.z, f Z 4 e, ,..„1,774, .
<br />..- - 0 OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL 0 0 SOIL BORING B
<br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS
<br />INDUSTRIAL 0 OPEN BOTTOM DIA. OF WELL EXCAVATION
<br />i 64 ,--,/,,f-'- / — , /-<_ ( i: r 1-1,,,....(t /
<br />DIA. OF cottbucron CASING (...-L44-... t,...7f- A CI D
<br />DOMESTIC/PRIVATE 0 GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA. OF WELL CASING D
<br />PUBLIC/MUNICIPAL 0 DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R
<br />IRRIGATION/AG CI OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E
<br />MONITORING GROUT SEAL PUMPED: 0 Yee 0 No CONCRETE PEDESTAL BY DRILLER: 0 Yoe 0 No s
<br />APPROX. DEPTH LOCKING CHESTER BOX/STOVE PIPE S
<br />PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER
<br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND
<br />REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH
<br />THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA. CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES
<br />THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF
<br />CALIFOR A," TN CANT MUST CA
<br />Signed
<br />4 -HO(RS IN A .51OCE F9.41 A R N$PECTIONS AT 12061 23. COMM ETE OF/AWING AT LOWER AREA PROVIDED.
<br />Title s-4 62-403a 7 D.,. A)777912 X
<br />PLOT PLAN (Draw to Soaks) Scale to
<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 OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED
<br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS.
<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 />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED
<br />(Complete in Triplicate)
<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 />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 APN# 47(6 2 7 1..)4_ c_ br iv-e Sioc‘4.,_
<br />THE FOLLOWING: " I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR VVHIC
<br />DEPARTMENT USE ONLY
<br />Application Accepted By Date elifi
<br />Grout Inspection By Date Pump Inspection By
<br />Area t 01P
<br />Date
<br />Destruction Inspection By Date
<br />Comment,: ri /1,c-i A
<br />ACCOUNTING ONLY: AIDS EAU/
<br />PE CODES FEE INFO AMOUNT REMITTED CHE t ASH _ RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE
<br />r r•--- (jOeS"
<br />/5-5-i7 /411/ 17/11/7 ° i6
<br />5 R 0 0 i t‘;' 5-4
<br />_
<br />•••
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