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ADDRESS LICIE PHONE <br />(TYPE OF PUMP) <br />NEW WELL <br />INSTALLATION <br />New 0 Repalr <br />TYPE OF WELUPUMP: REPLACEMENT WELL <br />WELL SYSTEM REPAIR <br />H.P. <br />OUT-OF-SERVICE WELL <br />MONITORING WELLS <br />CROSS-CONNECT REPAIR <br />DEPTH PUMP SET FT. <br />GEOPHYSICAL WELL <br />VAPOR EXTRACTION WELL <br />OTHER <br />FIRST WATER LEVEL 0 <br />W<011 BORING <br />4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM on 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. <br />PLOT PLAN (Drew to Etoe/e1 Scale <br />NAMES OF STREETS OR 1OADS 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 />s SE <br />o L iz I/1)4S <br />ApplIcatIon Accepted By <br />Grout InepectIon BY <br />1)4,..t.ntlen lnepon,lon fly <br />Cornrnmot•• <br />Date <br />Date Area <br />APPLICATION FOR WELL/PUMP PEP - <br />5. JOAQUIN COUNTY PUBLIC HEALTH S. /ICES <br />ENVIRONMENTAL HEALTH DIVISION <br />304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br />(209) 468-3420 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Crimple's In Triplicate) <br />APPLICATION IS IIEFIE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAOUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR APN/ V c o R. LANJE CITY l-O.L PARCEL 1312E/APNO <br />OWNER'S NAME ea uk i-o Es I-4-c. ADDRESS F BoKb 249 j CA-kso M 90719 PHONE 4559) 646 <br />11-• 5 e. <br />CONTRACTOR 717 DR LLII\)é ADDRESS 950 lip() E. RD, HART Nam, CS? - ifs - li6PHONE (92S) 313 -S71-00 <br />SUB CONTRACTOR <br />1 VIE8E13Y CERTIFY THAT I HAVE PREPARED THIS APPUCATION AND THAT THE WORK 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 WOES( FOR WHICH <br />11115 PERMIT 18 ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA. CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br />THE FOt. OWING: I C FY THAT IN THE PERE ANCE OF THE WOR( FOR WHICH THIS PERMIT IS ISSUED. I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CALIFOR CANT MUST CALL 24 IéOI.M1 IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 1200) 4111-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />LC( Doe / 31F/ P • <br />ACCOUNTING ONLY: AID/ FACK <br />PE CODES FEE INFO AMOUNT REMITTED CHECK/MASH RE -r BY , DATE REQUES PER INVOICE <br />....^ A <br />3'3 U I y ?, CC' / Z- 6y ,, / / e-// 37 , SIZOO 17-ci 0 3 <br />; <br />Pub. Health Serv. - Enviro. 173 (1/97) <br />66c - SIgnoel X Title <br />p Inspection By <br />DEPARTMENT USE ONLY <br />/1.,167 <br />Date <br />A TYPE OF WELL <br />0 OPEN BOTTOM <br />0 GRAVEL PACK/812E <br />0 DRIVEN <br />0 OTHER <br />DIA. OF CONDUCTOR CASINO <br />DIA, OF WELL CASINO <br />SPECIFICATION <br />GROUT BRAND NAME <br />CONCRETE PEDESTAL BY DRILLER: 0 Yee 0 No zte) <br />OTHER PROPOSED CONSTRUCTION/DRILUNO METHOD: MUD RD <br />El DESTRUCTION: <br />INTENDED USE <br />INDUSTRIAL <br />El DOMESTIC/PRIVATE <br />El PUBLIC/MUNICIPAL <br />0 IRRIGATION/AG <br />MONITORING <br />APPROX. DEPTH <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF WELL EXCAVATION <br />TYPE OF CASINO/STEEL/PV <br />DEPTH OF GROUT SEAL /V <br />GROUT SEAL INSTALLED BY <br />GROUT SEAL PUMPED: 0 Yea 0 No <br />LOCKING CHESTER BOX/STOVE PIPE <br /> AIR ROTARY AUGER -,/ CABLE