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APPLICATION FOR WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <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 />ORIGINAL <br />• <br />JAN 0 8 1999 <br /> <br />(Comptes In Triplicate, <br />APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOF9( DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />JOAQUIN COUNTY DEVELOPMENT TITLE. CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR APTIff 2_ 00 /V4 Ld e._1 I <br />OWNER'S NAME --12- / iie7 (3-ra it/ e s v <br />CONTRACTOR r' A /4 / /ii ty 1/I f ADDRESS Pterie 30 2 ..1 .4)ft :';'.4kal tiC9)-14igi 2 PHONE 626Z <br />qe), cu-v 77-1 t1ill PARCEL ElIZE/APNI/ <br />ADDRESS po S' -7 714 S. e <br />FUR CONTRACTOR ADDRESS <br /> <br />UCO PHONE * <br /> <br />TYPE OF WELT/PUMP: O NEW WELL 0 REPLACEMENT WELL 0 MONITORING WELLS 0 OTHER <br />INSTALLATION 0 WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELL 0 <br />(TYPE OF OF PUMP) <br />0 DESTRUCTION: Kt (lit) <br />PROPOSED CONSTAUCTIONTDRILUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE vvona WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN 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 WORK 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 CERTITIEC.„, <br />THE FOI LOWING: I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED, I SMALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS <br />CALIFORNIA THE APPUCANT MUST C U. 24 HOURS IN ADVANCE FOR ALL RECIUTRED INSPECTIONS AT I 4111-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Title ct C:3 CC CC' ist - Data Z -1 <br />INTENDED USE <br />INDUSTRIAL <br />DOMESTIC/PRIVATE <br />PUBLIC/MUNICIPAL <br />0 IRRIGATION/AG <br />MONITORING <br />I <br />APPROX, DEPTH 415 <br />N 0 Now 0 Repeir H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0 <br />0 OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELLS rk SOIL BORING '. IV ti?t, a p,,,,I.L4 <br />,, , <br />,A 8 <br />1 ,_ct a ild -fi 1 ttd bts/c'e 1,1464 ] tek-)71-- 'ike' -s ,.t.-,,,,; <br />CONSTRUCTION SPECIFICATIONS A <br />DIA. oE,er-r-racimsnorr 6`-' e. I A '--) S i I DIA. OF CONDUCTOR CASINO Al //-) <br />TYPE OF CASING/STEEL/PVC ti) A DIA. OF WELL CASINO <br />DEPTH OF GROUT SEAL 7-6 --t-c, ,-A Aid .r., SPECIFICATION <br />GROUT SEAL INSTALLED BY 1`6441 -'r e- GROUT BRAND NAME <br />GROUT SEAL PUMPED: 0 Yes 0 No CONCRETE PEDESTAL BY DRILLER: 0 Yea 0 Ne <br />A, LOCKING CHESTER BOX/STOVE PIPE <br />TYPE OF WELL <br />0 OPEN BOTTOM <br />0 GRAVEL PACK/912E <br />0 DRIVEN <br />0 OTHER <br />Slaned X lo <br />PLOT PLAN 113mw to Seale/ Scala to <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 />enucTunto, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. <br />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 />DEPARTMENT USE ONLY <br />Delo Application Accorted By //-9Y? Area a )4 fl‘: <br />Grout Inopectlen By Dote Oslo Pump Inspection By <br />Cornroonts: <br />Doett.mtlon IrnpectIon By <br />Ade 7d,a) <br /> <br />Date <br /> <br />COMPLETED <br />ACCOUNTING ONLY: AID* FACO <br />441"4 <br />PE CODES FEE INFO <br />, <br />AMOUNT REMITTED CHECKS/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />VK et27k /- P If <br />0 ii -1'1 <br />Pub. Health Serv. - Enviro. 173 (1/97)