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DEPARTMENT USE ONLY <br />Pump Inspection By <br />Y/ s''1.9 <br />Owe <br />Area <br />Date <br />ApplIcatInn Acertoted By <br />Orout InsproctIon By <br />Dooltuctlen Inemsellon By <br />Commenl•• f roiza <br />APPLICATION FOR WELL/PUMP PERT <br />JOAQUIN COUNTY PUBLIC HEALTH $. VICES <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 Triplicate) <br />APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE VVIIII SAN <br />JOAOUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1 1 1 5.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIV1810 <br />CITY 5 C PARCEL 131ZE/A1P441?10 0, 13 0 <br />OWNER'S NAME Cdv s Ciko Ora 1 ADDRESS 7 0 6 Al • 1 Dor 4 C16 <br />CONTRACTOR Act va 6.0 Ei1 t, i P4 0 4 et et 00 - WA; I P.1 1.4" ADDRESS — yuc, 6 50,-2- 7 PHONE S I 67- / 00 6 <br />SUB CONTRACTOR <br />TYPE OF WELL/PUMP: 0 NEW WELL <br />0 INSTALLATION <br />0 New 0 Repel/ <br />HYPE OF PUMPI <br />0 DESTRUCTION: <br />REPLACEMENT WELL <br />0 WELL SYSTEM REPAIR <br />H.P. <br />our-or-SERVICE WELL <br />ADDRESS <br />MONITORING WELL <br />CROSS-CONNECT REPAIR <br />DEPTH PUMP SET FT. <br />GEOPHYSICAL WELL I <br />UC4 PHONE <br />El OTHER <br />0 VAPOR EXTRACTION WELL II <br />FIRST WATER LEVEL <br />12I SOIL BORING <br />TYPE OF WEU. CONSTRUCTION SPECIFICATIONS ,4 0 OPEN BOTTOM DIA. OF WELL EXCAVATION 7. " __. <br />DIA. or CONDUCTOR CASINO V 0 GRAVEL PACK/SIZE TYPE OF CASING/STEEUPVC..... <br />DIA. OF WELL CASING — D 0 DRIVEN DEPTH OF GROUT SEAL T. I) - SPECIFICATION R 0 OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME 1011111 4 ck E <br />CONCRETE PEDESTAL BY DRILLER: 0 Y. 1:3No S <br />CABLE <br />OTHER 4/ J'S(..1- n <br /> t) <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND <br />REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 1 CERTIFY THAT IN THE PERFORMANCE OF THE 1NOW FOR WHICH <br />THIS rrnmrr IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA. • CONTRACTOR'S HIRING OR SUS-CONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: ' I CERTIFY THAT IN THE PERFORMANCE OF THE WOE4( FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CALIFORNIA. THE APPLICANT MUST CALL 24 HOLMill IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT (20111 4011-3423. COMPLETE DRAWING ATLOWER AREA PROVIDED. <br />Signed X 21LIA/;L- 1444./44/6"?'n Title 5I 1410 r 5 fa Ff 17' 3 "-Cl <br />PLOT PLAN (Drew to Seale) Seele <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 />to <br />4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM on PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />S. LOCATION OF VVELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />JOB ADDRESS/OR APNO 7 0 jki E. I DO lea d <br />PHONE , 'I c 7.66 ti <br />INTENDED USE <br />INDUSTRIAL <br />DOMESTIC/PRIVATE <br />PUBLIC/MUNICIPAL <br />IRRIGATION/AG <br />171 MONITORING <br />APPROX. DEPTH <br />PROPOSED CONSTRUCTION/DRILUNG METHOD: MUD ROTARY <br />? GROUT SEAL PUMPED: El Yea 131No <br />LOCKING CHESTER BOX/STOVE PIPE <br /> AIR ROTARY AUGER <br />•••••• <br />ACCOUNTING ONLY: AIDS PACO <br />PE CODES EE INFO AMOUNT REMITTED CHECK/MASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />3 col si <br />1 <br />rt. co (1-3 Cf1/1/ i /0 /2flg 0 7- 6 5-3 .--- <br />,--- S t,D0V1 0 5 3 ) <br />Pub. Health Serv. - Enviro. 173 (1/97)