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/AP
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<br />
<br />
<br />APPLICATION FOR WELL/PUMP PERMIT
<br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES
<br />ENVIRONMENTAL HEALTH DIVISION 00
<br />304 EAST WEBER AVENUE, STOCKTON, CA 95202
<br />11011-REFURDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED
<br />(209) 468-3420
<br />Olif
<br />JAN 0 7 *1999
<br />,, .A0111P.I COUNT!' 2
<br />4 0F2...
<br />(Complete In Triplicate) ,
<br />JOB ADDRESS/OR APNI
<br />TQLE, CHAPTER 9-1115.3 AND TH TAND 9 OF AN JOAO IN COU PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVI -SION. -
<br />__ APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN
<br />-- t cr I. . ''''•-• heif C re -irt-c-*-- PARCEL SIZE/APNI/ Q --_-, ..S....01 ..,' ...,. ‘....._ ' ,.......<
<br />‘,....,
<br />OWNER'S NAME 6,,,,,c1, , ...... ADDRESS 2..% -2-1 ki • C c...... , 1:p.ry,a ,;., 1-Wj ,, ‘::, .....,, 4e i... c C
<br />C 41-.40.1111116pai 41 4‘:.; c L-:,
<br />CONTRACTOR .E.,..1; f t.•,,,,,its..,..i ..,. 4 '---g,,,..:......A,...i-, cv........,... .-k--_,, .:. .
<br />ADDRESS 1;\--.14) fr,„Lit 4 )4Ic - ;Sittj, ele uc s Zo " '44 11 '''' PHONE t (ii6) 32. 'S- -cjibr
<br />RUB CONTRACTOE1 L.', ::----d."-'-'"-4-d" --I--; ‘. ; 1 ‘."- - ADDRESS 7' . 0 11,,...., "4" ?L ucg 1•• I C., ...--:,. PHONE 0 (1(--; )
<br />(A gli it
<br />TYPE OF WELUPUMP: 0 NEW WELL 0 REPLACEMENT WELL MONITORING WELL , A* 0 OTHER
<br />0 INSTALLATION 0 WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELL #
<br />0 Now 0 Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0
<br />(TYPE OF Pt/MPI
<br />0 OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELTS tr8011 BORING
<br />0 DESTRUCTION!
<br />
<br />TYPE OF WELL CONSTRUCTION SPECIFICATIONS
<br />0 OPEN BOTTOM DIA. OF WELL EXCAVATION IN.... ' DIA. OF CONDUCTOR CASING 1\-'t ' •-'
<br />El GRAVEL PACK/SIZE .1-q ••••• .1 TYPE OF CASING/ST FEUPVC e V i•-- C../1 1`.- DIA. OF WELL CASING 2. " o ,--
<br />El DRIVEN DEPTH OF GROUT SEAL /PBC- SPECIFICATION 7: )...i C.. `JO- jL R
<br />0 OTHER GROUT SEAL INSTALLED BY.-I! •••• ' •'• •-• '' • ti•••••:- GROUT BRAND NAME 2.--• 4' i ,,•••--ki ;• " .1.-.1 E
<br />GROUT SEAL PUMPED: Ely.. O N. CONCRETE PEDESTAL BY DEWIER! 0 Yee El No 5
<br />LOCKING CHESTER SOX/STOVE PIPE 5
<br />AIR ROTARY AUGER CABLE OTHER
<br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS. AND RULES AND c.•••
<br />REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING! 'I CERTIFY THAT IN THE PERFORMANCE OF THE WON( FOR WHICH
<br />THIS PERMIT 19 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 PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED. I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF
<br />CAUFORNIA.* THE APPUCANT MUST CALL 24 HOUPIS IN ADVANCE FOR ALL REOUIRED INSPECTIONS AT 1200) 405-0421. COMPLETE DRAWING AT LOWER AREA PROVIDED.
<br />JOAQUIN COUNTY 0511510
<br />PHONES
<br />INTENDED USE
<br />INDUSTRIAL
<br />DOMESTIC/PRIVATE
<br />PUBLIC/MUNICIPAL
<br />IRRIGATION/AG
<br />El MONITORING
<br />APPROX. DEPTH 4P21'
<br />PROPOSED CONSTRUCTIONMRILUNG METHOD: MUD ROTARY
<br />Signed X ANA., A 4-4,-- E RTC- TRIP S f-e,24 ctiy'
<br />
<br />Data I c
<br />
<br />PLOT PLAN (Draw to Boalol Seals
<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 OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED
<br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS.
<br />
<br />to
<br />
<br />4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED
<br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS.
<br />S. LOCATION OF WELLS WITHIN RAMS OF ONE HUNDRED FIFTY FT
<br />ON THE PROPERTY OR ADJOINING PROPERTY.
<br />ApplIcsIlem Accepted By
<br />DEPARTMENT USE ONLY
<br />WO
<br />44-
<br />Zz g9tArm Obgli
<br /> Dole (trout Inspection Sr
<br />
<br />Pump InypeetIon By
<br />
<br />DmImellen Impaction By ,
<br />c--.. 714.1) /M /S;' /?.t• ifs 2/b 2/5 224›. 751-7°-
<br />c_ . ,
<br />ACCOUNTING ONLY: AIDE FACE
<br />_ _ - -
<br />PE CODES FEE INFO AMOUNT REMITTED CHECK /CASH RECBVED BY DATE PEEWIT/6 BER INVOICE
<br />350 I WO
<br />e? o*"..--
<br />/ 25 6r /... 7_
<br />/
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