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PAYMENT
<br />APPLICATION FOR WELL/PUMP PERMIT --4-7.r.:FNFin
<br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES
<br />ENVIRONMENTAL HEALTH DIVISION DEC 0 2 -1991:
<br />304 EAST WEBER AVENUE, STOCKTON, CA 95202
<br />W-ki 4 •AJAQUIN GOUI\I I Y (209) 468-3420 PUBIJC HEALTH SERVICES - .VIRONMENTAL HEALTH NOM-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , DIVISION
<br />(Complete In TrIplientsI
<br />APPLICATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. 11119 APPLICATION IS MADE IN COMPLIANCE WITH SAN
<br />JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION.
<br />JOB ADDRESS/OR APNO /.$-63 V s7a,rva---6->(.4_ P0 -40, crry ivCite.,..4.1 PARCEL SIZE/APNS (2.2 9 --tac --cy ., ,..
<br />OWNER'S NAME 12.41-"0,-?A Gp...4-3z %RI)...4411" AoonEse 1 / 1 . "9..ir 4r 4'.,..4,.,,
<br />
<br />7 pHONE •
<br />CONTRACTOR Bs IL ,i 4.scic.:44 9,6 ,, _ ADDRESS 7/.41C),tr 41441,.. ..4. UCS IM) rIg.1 PHONE i C.---...S...1
<br />
<br />SUB CONTRACTOR ADORESS MO PHONES
<br />REPLACEMENT WELL 43:-MONITORINO WELL I 0 OTHER
<br />WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION VVELL 1/
<br />H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0
<br />OUT-OF-SERVICE WELL
<br />
<br />0 GEOPHYSICAL WELLS "'"54.....SOIL BORING /ct
<br />TYPE OF WELL/PUMP:
<br />(TYPE OF PUMPI
<br />it+411,1
<br /> WELL
<br />0 INSTALLATION
<br />0 New 0 Repel,
<br />(-I '
<br />IN
<br />I I
<br />t'SPE....--bo L.sca,
<br />/2 - 2- 9i
<br />Delo
<br />ApplleetIon Aceepted By
<br />°rout Impaction BY
<br />Deetrectlen Inspection By
<br />Convey/ow
<br />
<br />ji "DEPARTMENT USE ONLY
<br />
<br />ill 11- ----
<br />Pump Incpectlen By
<br />Delo
<br />ACCOUNTING ONLY: AIDS FAC/
<br />PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECBV Y DATE PERMIT/SERVICE REQUEST NUMBER INVOICE
<br />gift"; 4' 8`7.oc -* 2-1L1- C,
<br />/ ii,,,,, 1 2/z lig,
<br />.,,L.,,,11.,, r,
<br />Pub Health Serv. - Enviro. 173 (1/97)
<br />•
<br />0 DESTRUCTION:
<br />p_MONITORING GROUT SEAL PUMPED: gi-Ve• O N, CONCRETE PEDESTAL BY DRILLER: 0Y.. ON. $
<br />0 IRRIGATION/AG 0 OTHER GROUT SEAL INSTALLED BY 12 S4'r...- GROUT BRAND NAME E
<br />DOMESTIC/PRIVATE $1.I3RAVEL PACK/817E '71 f. TYPE OF CASING/STEELIT'VC n vc DIA. OF WELL CASING /?' " 0
<br />PUBLIC/MUNICIPAL 0 DRIVEN DEPTH OF GROUT SEAL e/ - . 1, SPECIFICATION R iFnii."." - . 124- {Ater R
<br />0 INDUSTRIAL 0 OPEN BOTTOM •- _/
<br />)--
<br />DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASINO Et
<br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS
<br />'
<br />A C. ....---
<br />APPROX. DEPTH LOCKING CHESTER BOX/STOVE PIPE LX--- 5
<br />PROPOSED CONSTRUCTION/DRILUNO METHOD: MUD ROTARY AIR ROTARY AUGER Nte,...._ CABLE OTHER
<br />I HERESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WON( 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 TH T /N THE PERFORMANCE OF THE VVORK FOR WHICH THIS PERMIT IS ISSUED. I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF
<br />CAUFORNIA.- T ANT yT C4/2) HOURS IN ADVANCE FOR AU, REQUIRED INSPECTIONS AT 12011 411-3423, COMPLETE DRAWING AT LOWER AREA PROVIDED.
<br />TItle L??- /11C /1/14-A14 4->- Date - Signed X
<br />is PLOT PLAN (Drew to %Nei Scale to
<br />I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY.
<br />2. OUTLINE OF THE PROPERTY. WING DIMENSIONS AND NORTH DIRECTION.
<br />T. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED
<br />STRUCTURES. INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS.
<br />4. 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 OR ADJOINING PROPERTY.
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