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APPLICATION IS HERE BY MADE TO THE <br />JOAOUIN COUNTY DEVELOPMENT TITLE <br />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 />Maniples In Triplicate, <br />SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />, CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR APN/I j3 cflo -03 05 Ai. Tri4- <br />OWNER'S NAME A at.° pr,s0C-AS, 1--CVM1Ot1•--' <br />CONTRACTOR F( <br />SUB CONTRACTOR II I <br />ADDRESS . e") 44-)X, L goi C dPHONE <br />ADDRESS itttAj4 ‘C kl 6,7VOPHONE S611-1A0 <br />ZoX 3011 ac,N="7 0 ADDRESS ,666: MON <br />CITY PARCEL SIZE/APNO <br />TYPE OF WELL/PUMP; NEW WELL <br />INSTALLATION <br />El Now 0 RopeIr <br />REPLACEMENT WELL <br />0 WELL SYSTEM REPAIR <br />W/F."-.40NITORING WELLS <br />0 CROSS CONNECT REPAIR <br />DEPTH PUMP SET FT. <br /> <br />OTHER <br />VAPOR EXTRACTION WELL I <br />FIRST WATER LEVEL <br /> <br />0 <br /> <br />(TYPE OF PUMPI <br /> <br />OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL 0 <br /> <br />SOIL BOAING <br /> <br />0 DESTRUCTION: <br /> <br />TYPE OF WELL <br />1 9PEN BOTTOM <br />ItIORAVEL PACK/SIZE. CO <br />INTENDED USE <br />0 INDUSTRIAL <br />DOMESTIC/PRIVATE <br />PUBLIC/MUNICIPAL 0 DRIVEN <br />IRRIGATION/AO 0 OTHER <br />MONITORING <br />) <br />APPROX. DEPTH LI...) <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF WELL EXCAVATION <br />TYPE OF CASINO/STEEL/PVC <br />DEPTH OF GROUT SEAL <br />GROUT SEAL INSTALLED BY <br />GROUT SEAL PUMPED. r4 so O N, <br />LOCKING CHESTER BOX/STOVE PIPE <br />PROPOSED CONSTRUCTLON/DFOLUNG METHOD: MUD ROTARY AIR ROTARY <br />A <br />DIA. OF CONDUCTOR CASINO <br />DIA. OF WELL CASINO fi <br />SPECIFICATION <br />0 <br />GROUT BRAND NAME <br />CONCRETE PEDESTAL BY ()FULLER: 0 Yoe 0 No <br />eXI9P)4411 CP,e eM LO k-.4-41U''' L41 6A(11 <br />AUGER / CABLE OTHER <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APF1JCATION AND THAT THE WOW. 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 UCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br />THIS PERMIT IS ISSUED, 1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: " 1 CERTIFY THAT IN THE RFO ANCE OF THE WOW FOR WHICH THIS PERMIT 18 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CAUFORN1A.• THE PP1JCANT MUST CALL IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12001 4911-11,4211. COMPLETE DRAWING AT DINER AREA PROVIDED. <br />Signed X <br /> <br />PLOT PLAN (Drew to Boole' Seal. <br />I. NAMES OF STREETS OR ROADS NEAREST R BOUNDING THE PROPERTY. <br />OUTLINE OF THE PROPERTY, GIVING DIME • NB AND NORTH DIRECTION. <br />DIMENSIONED OUTIJNFII AND LOCATION OF ALL EXISTING AND PROPOSED <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DfVVEVVAYS, AND WALKS. <br />S fTAC4c Fufc_ r‘, <br />Title51:37(1) pf/atel_,,,,;* 4-1Y-f(A5-el" <br />(e,---tT I vt.,_ TO <br />- 39 <br />4. LOCATION OF HOU DISPOSAL SYSTEM OR PROPOSED <br />EXPANSION OF SEWAGE DISPQAI SYSTEMS. <br />S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />Appllootton Acoopied By J.-->LAA."-rC.A L.""\ <br /> <br />DEPARTMENT USE ONLY <br /> <br />Delo <br /> <br />Dote kI,17 4t Pump InopectIon By <br /> <br />Grout Impaction By liO'N-AAA,...," <br /> <br />Delo <br /> <br />DootroctIon Inypoolloo By <br /> <br />D.I. <br /> <br />Comments! <br /> <br />ACCOUNTING ONLY: AIDS FACI <br />PE CODES FEE INTO AMOUNT REMITTED CHECKS/CASH RECDVED BY DATE PEANUT/SERVICE REQUEST NUMBEF1 INVOICE <br />3 C 0 1 -it c-601 , r) 0 9- ii / % 9 ' . . <br />C ---s' go D\saS9 s, ,- <br />Pub Health Serv. - Enviro. 173 (1/97)