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NEW WELL <br />INSTALLATION <br />ID New ID Revak <br />REPLACEMENT WELL <br />WELL SYSTEM REPAIR <br />H.P. <br />Ve MONITORING WELL # 0 OTHER <br />0 CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELL I <br />DEPTH PUMP SET FT. FIRST WATER LEVEL <br />TYPE OF WELL/PUMP: <br />RYFf OF PUMP) 0 <br /> <br />Applicsaloyt Actospisel By <br />Grout Inopectlefi By <br /> <br />ID.Ntletlen !metered°. fly <br />Cornmentr <br />D.,. 1ti?,4 <br />Delo <br />.... .... . <br />'r\-c Dem <br />DEPARTMENT USE ONLY <br />APPLICATION FOR WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTFI SERVICES <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 JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED. THIS APFLICATION IS MADE IN COMPLIANCE WITH SAN <br />JOAOUIN COUNTY DEVELOPMENT MtlkCIA .3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION, <br />JOB ADDRESS/OR APNff Fit hrre <br />i <br /> <br />OWNER'S NAME / 1 (if, Lad 1 <br />CONTRACTOR it Ct 1/4 00,4 tnot 14 <br />SUB CONTRACTOR 5,i; > F-)tr IC eLl to A 5.,r <br />G I 5 I'. '1' CITY LAOCI f <br />ADORERS 1;'1 rit4 <br />ADDRESS 400 .5' 1/4- 1 O•1 14/ <br />ADDRESS 341 ret'llTrilf <br />Cff 6101)- 7 PHONE 0:11 1 10)0)6 ,2. <br /> 1-,U CI CV CIL PHIRE # 34/ <br />SIZEJAPH# <br />PHONE I)/ - 6 to 6 <br />OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL <br /> <br />0 ROIL ROTUND <br />DESTRUCTION: <br />INTENDED USE <br />INDUSTRIAL <br />DOMESTIC/PRIVATE <br />PUBLIC/MUNICIPAL <br />mniamioN/A0 <br />VI MONITORING <br />APPROX. DEPTH <br /> 6 <br />TYPE OF WELL <br />0 OPEN BOTTOM <br />3 III GRAVEL PACK/SIZE <br />0 DRIVEN <br />0 OTHER <br />CONSTRUCTION SPECIFICATIONS <br /> <br />DIA. OF WELL EXCAVATION <br /> <br />TYPE OF CASING/STEEL/PVC <br /> evc: <br />DEPTH OF GROUT SEAL <br />GROUT SEAL INSTALLED BY <br />GROUT SEAL PUMPED: EA Yee Ci N. <br />LOCKING CHESTER BOX/STOVE PIPE <br /> AIR ROTARY AUGER if\ CABLE OTHER PROPOSED CONSTRUCTIONTDRILUNO METHOD: MUD ROTARY <br />A <br />DIA. OF CONDUCTOR CASING <br />DIA. OF WELL CASING <br />SPECIFICATION <br />GROUT BRAND NAME re.-licvtd <br />CONCRETE PEDESTAL BY DRILLER: 0 Yee 121.Ne <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATION 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 VVOFIK FOR WHICH <br />THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA. COMPACTOR'S HIRING OR RUB-CONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: ' I CERTIFY THAT IN THE PERFORMANCE OF THE WOW 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 AU. REQUIRED INSPECTIONS AT MORI 4191.1421. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />7:1)24/4*% T1401- 74/(1/641 Title Ye- 51.7ff iof Maned X 11 -1q -(1-9 <br />to PLOT KAN /Chew te Seelel S.I. <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 AL). 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 />S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />ON THE PROPERTY on ADJOINING PROPERTY. <br />ACCOUNTING ONLY: AIDS PAC/ <br />PE CODES FEE INFO AMOUNT REMITTED CHECKOASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBITI INVOICE <br />360\ 3 at ----31 )/(,, 0-0 (-?_0 <br />Pub Health Serv. - Enviro. 173 (1/97)