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APPLICATION FOR WELLIPUMP PERMIT <br />AN JOAQUIN COUNTY PUBLIC HEALTH SERVICto <br />ENVIRONMENTAL HEALTH DIVISION <br />P.O. BOX 383.304 EAST WEBER AVENUE, STOCKTON, CA 95201-388 <br />(209) 4691420 <br />PION-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete in Triplicate) <br />APPLICATION IS HERE BY MADE TO THE SAN JOAOU1N COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 16 MADE IN COMPLIANCE mill SAN <br />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 APTIS 40 Xl zia,-„,k).571 CITY Skc_k-i-ezt <br />OWNER'S NAME 6 em t Gickt-In Uri ADDRESS -lb &II( 12.A0 lre., PHONE ...7/10 4 7 7- g,3 <br />CONTRACTOR IZS ADDRESEL3n sken'sP1. hik Sfr1 5; uc 7.44HT6S PHONE oza) 7 7,2 -3570 <br />SUB CONTRACTOR ADDRESS Lief <br />PARCEL SIZE/APNI/ <br />PHONES <br />TYPE OF WELL/PUMP: 0 NEW WELL <br />0 <br />o <br />INSTALLATION <br />New 0 Repair <br />REPLACEMENT WELL <br />WELL SYSTEM REPAIR <br />H.P. <br />MONITORING WELLS <br /> <br />OTHER <br />VAPOR EXTRACTION WELL <br />FIRST WATER LEVEL <br /> <br />CROSS-CONNECT REPAIR <br /> <br />DEPTH PUMP SET FT. <br />GEOPHYSICAL WELL S <br /> <br />(TYPE OF PUMP/ <br /> <br />OUT-Or SERVICE WELL ErSOIL BORING - <br /> <br />0 DESTRUCTION: <br />INTENDEDINTENDED USE <br />INDUSTRIAL <br />CI DOMESTIC/PRIVATE <br />PUBLIC/MUNICIPAL <br />IRRIGATION/AG <br />MONITORING <br />APPROX. DEPTH 3O -Peet <br />TYPE OF WELL <br />0 OPEN BOTTOM <br />GRAVEL PACK/SIZE <br />0 DRIVEN <br />0 OTHER <br />PROPOSED CONSTRUCTION/DRILUNG METHOD: MUD norAny <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF WELL EXCAVATION 1g( DIA. OF CONDUCTOR CASINO <br />TYPE OF CASING/STEEL/PVC _DIA. OF WELL CASING <br />DEPTH OF GROUT SEAL Ny.0/ (Pfrelt <br />GROUT SEAL INSTALLED BY (tei tkPr GROUT BRAND NAME <br />GROUT SEAL PUMPED: 0 Yee 111,No CONCRETE PEDESTAL BY DRILLER: El Y. 0 No <br />LOCKING CHESTER BOX/SI OW PIPE_ <br />AIR ROTARY AUGER CABLI OTHEn_cl <br />A <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAI 1HE WORK WILL BE DONE IN ACCORDANCE WITH n ' H JOACItii , ':OUNTY ORDINANCES. STATE LAWS. AND RULES AND <br />REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSIT, AGENT'S SIGNATURE CERTIFIES THE FOLLOWItao '1 CERTIL . ?HAT 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 FOLLOWING: " I CERTIFY THAT IN THE PERFORM OF THE WOFK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' THEApPLIAANX,M5UA CALL 4 HO <br />CAI behatt I-I <br />DVANCE FOR ALL REQUIRED INSPECTIONS AT 1201.14444423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />T----- <br />(5604;,/C'-f Dine Signed X Tit?. <br />In PLOT (Drew to %We/ Scale <br />I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING TIt 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 />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 />Application Accepted BY tle\ASIASCAel 01-e— ).........rigs: <br />Grout loypoctIon By ' ...) 6 7-I i <br />DootructIon InspectIon Sy (... <br />Comment: <br /> <br /> Delo Ares <br />Date p Intlp t I n By Data <br /> <br />Gine <br /> <br />ACCOUNTING ONLY: AIDS FACS <br />PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />449 . on 0 aegis II i II c 11 LI <br />Pub. Health Serv. Enviro. 173 (3/96)