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JOB ADDRESS/OR APPI4 2427 frk fgA liasfin, <br />OWNER'S NAME 46F IA/6- <br />CONTRACTOR CAL /ç\/(, <br />SUB CONTRACTOR <br />CITY M7,44--/-Cezg PARCEL SIZE/APN4 S Mai° <br />ADDRESSO/ Grz•Ittoirl ge-11 R. STD -11-7, 4r PHONE ':22/ n'S----23/031 <br />ADORE/3E1 2040 b/24/,,) ji2.j PHONE 707— 4,1"--1162-7wp 44- uc• C-57 ,"2125PHoNE ?r-2f/ ADORES <br />DEPARTMENT USE ONLY <br />ApplIcollen Acoopted By <br />Grout Inspection By Date 'qi/C\C )4 <br /> <br />Pump Inspection By <br />Date Area <br />Date <br />PPLICATION FOR WELL/PUMP PER <br />SA. ..JAQUIN COUNTY PUBLIC HEALTH <br />PER <br />ENVIRONMENTAL HEALTH DIVISION <br />304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br />(209) 468-3420 <br />NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br />(Complete In Triplicate) 4"j 57 ett- <br />APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/011 INSTALL THE WOPS( DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WRIT SAN <br />JOAOUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1 115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />NEW WELL <br />INSTALLATION <br />0 Now 0 Rapid( <br />TYPE OF WELL/PUMP: <br />(TYPE OF PUMPI <br />CI DESTRUCTION, <br />El REPLACEMENT WELL <br />0 WELL SYSTEM REPAIR <br />H.P. <br />0 OUT-OF-SERVICE WELL <br />a MONITORING WELL S 0 OTHER <br />CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION VVELL / <br />DEPTH PUMP SET FT. FIRST WATER LEVEL <br />GEOPHYSICAL WELL <br /> 0 SOIL BORING <br />0 <br />a <br />INTENDED USE TYPE OF WELL <br />INDUSTRIAL <br /> <br />O OPEN BOTTOM <br />0 DOMESTIC/PRIVATE <br /> O GRAVEL PACK/SIZE <br />PUBLIC/MUNICIPAL <br /> 0 DRIVEN <br />IRRIGATION/AG <br />OTHER <br />0, MONITORING <br />APPROX. DEPTH <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF WELL EXCAVATION <br />TYPE OF CASING/STEEL/PVC <br />DEPTH OF OF GROUT SEAL 4, <br />GROUT SEAL INSTALLED BY <br />GROUT SEAL PUMPED: El Yes No <br />LOCKING CHESTER BOX/STOVE PIPE <br />DIA. OF CONDUCTOR CASING NA - <br />DIA. OF WELL CASINO 2_, <br />SPECIFICATION <br />GROUT BRAND NAME ?c,t---1 17_ <br />CONCRETE PEDESTAL BY DRILLER: Li Ye. 0 No <br />A <br />PROPOSED CONSTRUCTIONTDRILUNG METHOD: MUD ROTARY <br />AIR ROTARY AUGER X <br /> <br />CABLE OTHER <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOPK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE TAWS, 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 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 WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CALIFORNIA." THE APPUCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12051 441113422. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Signed X Title p <br />ica/Ls , ay <br /> <br />Date Z 7 - gs <br /> <br />PLOT PLAN (Draw to Scale) Scale • to <br />I NAMES or STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM on PROPOSED <br />OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. 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 ET <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br />OrryIrtsctIon Impaction By Dots <br />C 0.11171Iff OS: <br />ACCOUNTING ONLY: AIDS FACO <br />PE CODES FEE INFO AMOUNT REMITTED CHECK4/CASII RECEIVED SY DATE ent.17r Irerrorctellisar.avieseu--- ------ - -- INVOICE <br />S CO I lig et'00 l' 3 I, 6s- (AL ce 1,t, Vi g n L 6 S Li <br />Pub. Health Serv. - Enviro. 173 (1/97)