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4-75-xiele_&C <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 />(Camplate hi Triplicate) <br />APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WT111 SAN <br />JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1 1 15.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR AM/ C.) 5 1/.45r 14 flue crry '77')Z? PARCEL PARCEL SIZEJAPAIS <br />liatt/A 0/7‘?.... ADDRESS I 64/4,1 ( i_ OWNER'S NAME PHONE g.5 /411k <br />CONTRACTOR 441a -'12 OrL.,;\ 61)L)ei-S ADDRESS 4005 A4r3e0/ /52k/ UCS zi" D22 2 p/40/t„ /61;4 <br />SIM CONTRACTOR :)/i(V) ADDRESS <br />(d1-50 <br />.m••• <br />UCS PHONE <br />0 NEW WELL 0 REPLACEMENT WELL 0 MONITORING WELL S 0 OTHER <br />0 INSTALLATION 0 WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELL S J <br />0 New 0 Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0 <br />0 OUT-OF-SERVICE WELL 0 OEOPHYSICAL WELL S <br /> 1,-;e8011 BORING <br />TYPE OF WELL/PUMP <br />(TYPE OF PIJMPI <br />0 DESTRUCTION: <br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br />DIA. OF CONDUCTOR CASING <br />flee <br />SS \`‘ <br />0 INDUSTRIAL <br />0 DOMESTIC/PRIVATE <br />0 PUBLIC/MUNICIPAL <br />o IRRIGATION/AG <br />ja MONITORING <br />APPROX. DEPTH <br />0 OPEN BOTTOM <br />0 GRAVEL PACK/SIZE <br />DIA. OF WELL EXCAVATION 2' <br />TYPE OF CASING/STEEUPVC A44- DIA OF WELL CASINO <br />0 DRIVEN <br />0 OTHER <br />2315- r•ie,f <br />DEPTH OF GROUT SEAL SPECIFICATION <br />GROUT SEAL INSTALLED BY 77) GROUT BRAND NAME <br />GROUT SEAL PUMPED: 0Y.. afic <br />LOCKING CHESTER BOX/STOVE PIPE <br />CONCRETE PEDESTAL BY DRILLER: 0 Yee ON, <br />PROPOSED CONSTRUCTION/DIVLUNG METHOD: MUD ROTARY <br />I HERESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE VVORK Will BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES. STATE LAWS, AND RULES ANOrt-, <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 VVOFK FOR WHICHk <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 PERFORMANCE OF THE WOFV( FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CAUCORNIA. THI CANT MUST CA 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 1201) 401-34231. COMPLETE DRAWING AT LOWER AREA PROVIDED. / • <br /> D.. //2 <br />AIR ROTARY AUGER CABLE OTHER L'..74Zr <br />0 PLOT PLAN Whew to Soule) Scale • to <br />I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. "(1 <br />DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br />Stoned X Title <br />DEPARTMENT USE ONLY <br />ApplieetIon Accepted By <br /> Delo .7.0 I 51Ar..411, 47 <br />Grout Inspection By <br /> Date Pump Impaction By Del. Date <br />Deettuctlen InerectIon By \---/Y\ • OCL- Del. <br />Comments: <br />ACCOUNTING ONLY: AIDS FAC/ <br />PE CODES FEE INTO AMOUNT REMITTED CHECKS/CASH RECEIVED BY DATE PERIAIT/ILEBYLCEJIPILIEBT_LIUMBER ....s...‘\ INVOICE <br />'7)C) <br />...f...) <br />fr.,.', i / / fk 1 _....-1 %Iwo 0304- <br />Pub Health Serv. - Enviro. 173 (1/97)