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.. • <br />........ <br />... <br />ogik -E.14sT11-16- <br />‘1*‘po•- Ta4.--u. <br />ti•-• <br />... <br />cf , Par, Pas4c) (-a <br />... <br />6 1.4 <br />AonlIcollon Ace.olfwl By <br /> CIA\--vt-,-er— <br />(boot Ineoricilon By (AC JAMACI"‘ Dote <br />DEPARTMENT USE ONLY <br />2 -1441 Ven, p Inspection By <br />1 Area <br />Date <br />Dole <br />IOW <br />APPLICATION IS IIERE BY MADE TO THE <br />JOAQUIN COUNTY DEVELOPMENT TITLE <br />JOB ADDRESS/OR APNO 1612— <br />OWNER'S NAME <br />CONTRACTOR <br />RUB CONTRACTOR <br />NPPLICATION FOR WELL/PUMP PERM ' <br />SA I JAOUIN COUNTY PUBLIC HEALTH SE. ,CES <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 Trinkets) <br />SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE VVITII SAN <br />. CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />Lk AAVUM.e.(4._ <br />ADDRESS <br />IJCS PHONES <br />44-co Pe-ockic-cs <br />11-1.4 a G. <br />LJ CITY S -1-C2C -'7.01%1 PARCEL SIZE/APHS <br />LA pk...."4 C4 114- 470 5000 ADDRESS Ceerrce_poi..,k-c C6.2.3 ei23 PHONE # <br />(24c)ibi.4 C.4 1c27 374 ADDRESS Po g 33' 94" ucir 7 1 00-21 PHONE <br />TYPE OF WELL/PUMP: P 'NEW WELL <br />0 INSTALLATION <br /> 0 New 0 Reeler <br />RYPE OF PUMP' <br />REPLACEMENT WELL <br />0 WELL SYSTEM REPAIR <br />H.P. <br />MONITORING WELLS <br />CROSS-CONNECT REPAIR <br />DEPTH PUMP SET FT. <br />Xr0THER Ale spA44E__ As-,-2.,-3 <br />,,,ErVAPOR EXTRACTION WELL I VW - S s, D J <br />FIRST WATER LEVEL 0 <br />OUT-OF-SERVICE WELL <br /> O GEOPHYSICAL WELL a' <br /> 0 sow noruno <br />IF <br />0 DESTRUCTION: <br />INTENDED USE TYPE OF WELL <br />INDUSTRIAL <br /> 0 OPEN BOTTOM <br />DOMESTIC/PRIVATE <br /> <br />'GRAVEL PACK/SIZE <br />PUBLIC/MUNICIPAL <br /> 0 DRIVEN <br />IRRIGATION/AG <br /> 0 OTHER <br />.1K MONITORING lize„Aer,,A-,--, <br />APPROX. DEPTH <br />PROPOSED CONSTRUCTION/DRILUNO METHOD: <br />CONSTRUCTION SPECIFICATIONS .4 <br />- 1 DIA. OF WELL EXCAVATION _SYS 0<paec e_ _ A., 64 <br />F 4-- <br />DIA. OF CONDUCTOR CASING <br />L4A-e *3 Serit.re.rE OF CASING/STEEUP s,r VC DIA. OF WELL CASING 2 I ot 4 <br />DE ISPAIEe. AS pi SPECIFICATION DEPTH OF mo SEAL 5 . tif E, 4f S CIA AO Ps/ C.. IF <br />GROUT SEAL INSTALLED BY 79-0,...ntE-_- °FLOUT BRAND NAME <br />GROUT SEAL PUMPED.yee O N. CONCRETE PEDESTAL BY DRILLER: ['Yee 0 No <br />LOCKING CHESTER BOX/STOVE PIPE <br />AUGER CABLE OTHER MUD ROTARY AIR ROTARY <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE VVORK 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 WOW 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.' APPUCANT MUST CALL 24 HOURS IN ADVANCE FOP nu REOUIRED INSPECTIONS AT 120111 488.2422. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Signed X /4 <br />4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM on PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />B. LOCATION OF VVELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />Title -Mai c.-r <br />PLOT PLAN (Drew to Boole) Scale I SIC•4 to____62/2 <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 />... <br />- <br />• <br />DomotrIrmtlem Inen.etIon Ely <br />Commeorit•: <br />ACCOUNTING ONLY: AIDE FACE <br />— <br />PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECEIVED BY DATE PERMIT/SERVICE REOUEST NUMBER INVOICE <br />5611 1 ccei .00 0 c001. cl (1,c ig <br />466 /6,6 t <br />Pub. Health Serv. - Enviro. 173 (1/97)