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APPLICATION FOR WELL/PUMP PERMIT <br />JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />EAST WEBER AVENUE, STOCKTON, CA 95202 <br />(209) 468-3420 <br />NOICREFURIDABLE 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 VVORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />JOAQUIN COUNTY DEVELOPMENT TRU. CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />cm Le oti PARCEL SIZEJAPNa <br />ADDRESS Li 1 4.0, t• Rtdr <br />Ackd'i214Crq -,G E0V twt 1,0141 414 <br />SUB CONTRACTOR 5Ci 1 GIN./ )i 601 v (4.1, 4rk ( <br />TYPE OF WELL/PUMP: 0 NEW WELL <br />0 INSTALLATION <br /> 0 New 0 Repair <br />(TYPE OF PUMP' <br />REPLACEMENT WELL <br />ID WELL SYSTEM REPAIR <br />H.P. <br />Cd MONITORING WELL 0 OTHER <br />CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELLS J <br />FIRST WATER LEVEL DEPTH PUMP SET FT. <br />OUT-OF-SERVICE WELL <br /> O GEOPHYSICAL WELL <br /> IA SOIL BORING <br />0 DESTRUCTION: <br />PAYMENT" <br />FZFCEi•;IV.F.T., <br />JAN 1 2 1999 <br />SAN ,I0AOUIN COUNTY <br />PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />SAN <br />304 <br />CONTRACTOR <br />OWNER'S NAME <br />JOB ADDRESS/OR APN (543 -0 01 .-10 1,1/ <br />Ci"l y Loci <br />r <br />PHONE 43)3 - 70 <br />ADDRESS DC i IV Wr IAA( /15 tit 4; (a '30 ...)-)" PHONES 1,I 1.00 L <br />ADDRESS CS 1Cruf lv 113/v )5(a...tics 5c1•1.06 pai 314 2)'2 <br />TYPE OF WELL <br />0 OPEN BOTTOM <br />0 GRAVEL PACK/SIZE <br />El DRIVEN <br />0 OTHER <br />INTENDED USE <br />0 INDUSTRIAL <br />DOMESTIC/PRIVATE <br />El PUBLIC/MUNICIPAL <br />IRRIGATION/AG <br />lid MONITORING <br />APPROX. DEPTH <br />CONSTRUCTION SPECIFICATIONS , <br />g <br />•••••• <br />P <br />GROUT SEAL INSTALLED BY 11,0 01 <br />GROUT SEAL PUMPED: 13Y.* D uo <br />LOCKING CHESTER BOX/STOVE PIPE <br />A <br />DIA. OF CONDUCTOR CASINO o <br />DIA. OF WELL CASING <br />SPECIFICATION <br />GROUT BRAND NAME PoA Iota, <br />CONCRETE PEDESTAL BY DRILLER: 0 Yea GiNe <br />DIA. OF WELL EXCAVATION <br />TYPE OF CASINO/STEEL/PVC <br />DEPTH OF GROUT SEAL <br />PROPOSED CONSTRUCTION/OAKUM° METHOD: MUD ROTARY AIR ROTARY AUGER CABLE <br />OTHER <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATION AND THAT THE WOR( 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 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 CERTIFIES <br />THE FOU.OWING: • I CERTIFY THAT IN THE PERFORMANCE OF THE WORK 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 12001 4014423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />8111.44 X j1t.J21,44‘. 114/1.4111.04/144arfri Title 54 14,, ." 5-1461. (,•,0 1:07 5 T Data II :.)/I1 17(03 <br />PLOT PLAN (Drew to Roele) Scale <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 OUTUNES AND LOCATION OF ALL EXISTING AND PROPOSED <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WAU(S. <br />to <br />4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />I. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY PT. <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />DEPARTMENT USE ONLY <br />Application Accepted By <br /> 1 <br />Area <br />Grout Inspection By <br /> t/(-A AAA Cr/V‘ Oslo I Pump InirpectIon By Date <br />Onetmellon tnilnectIon By <br />Comment*: <br />ACCOUNTING ONLY: AIDS FACO <br />PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECBVED BY DATE INVOICE T/SERVICE REQUEST NOMIHr„ <br />1 <br />.........../' <br />Pub Health Serv. - Enviro. 173 (1/97)