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Dots "ra Aro* 0 SIC <br />fr-f ADDRESS <br />Pump Inspection By Dote <br />n-g Asyilcellen Acoetptrx1 By <br />Grout InspoctIon By <br />( <br />DenetrticIlon Inspection By <br />Cnrnmetite• <br /> oco (i (/ <br />-.5' /7./ i•i)-.Y rt. <br />APPLICATION FOR WELL/PUMP PE . 'T <br />JOAQUIN COUNTY PUBLIC HEALTH .VICES <br />ENVIRONMENTAL HEALTH DIVISION <br />304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br />(209) 468-3420 <br />NON•REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br />(Complete In Triplicate, <br />APPLICATION IS IIEFtE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/011 INSTALL THE WOPK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE <br />WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE. CHAPTER 9-1 1 1 5.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY F'UBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR APNE <br />OWNER'S NAME ,...52ie/ 64 (n. cAD.,„..z6,50 ir.?„,50;4.e ,46( rHONE ,(707.)yz‘-z ?5/ <br />CONTRACTOR <br />SUB CONTRACTOR _512EZ-1lb4 fy,444/) <br />ZO <br />O DESTRUCTION: (9C +Virce_ q 1 <br />OUT-OF-SERVICE WELL <br />Yitttlil r \ <br />GEOPHYSICAL WEU_ I 0 SOIL BORING <br />CONSTRUCTION SPECIFICATIONS <br />TYPE OF WELL/PUMP: 0 NEW WELL <br />INSTALLATION <br />0 New 0 Repel, <br />(TYPE OF PIJMPI <br />0 REPLACEMENT WELL <br />WELL SYSTEM REPAIR <br />H.P. <br />MONITORING WELL <br />CROSS-CONNECT REPAIR <br />DEPTH PUMP SET FT. <br />OTHER <br />VAPOR EXTRACTION WELL E <br />FIRST WATER LEVEL <br />DIA. OF CONDUCTOR CASING <br />TYPE OF CASING/STE VC DIA. OF WELL CASING V <br />DEPTH OF GROUT SEAL I. rrtrio-g_ SPECIFICATION <br />4 A-r <br />GROUT SEAL INSTALLED BY O.- TRVA GROUT BRAND NAME e)rilCoACI <br />GROUT SEAL PUMPED:,. 0 No CONCRETE PEDESTAL BY DRILLER: 0 Y. 0 No <br /> <br />LOCKING CHESTER BOX/STOVE PIPE <br /> AIR ROTARY AUGER v/ CABLE OTHER PROPOSED CONSTRUCT-ION/DR/LUNG METHOD: MUD ROTARY <br />DIA. OF WELL EXCAVATION 10 <br />A INTENDED USE <br />INDUSTRIAL <br />0 DOMESTIC/PRIVATE <br />PUBLIC/MUNICIPAL <br />IRRIGATION/AG <br />ASS MONITORING <br />APPROX. DEPTH <br />TYPE OF WEU. <br />0 OPEN BOTTOM <br />0 GRAVEL PACK/SIZE <br />1:1 DRIVEN <br />0 OTHER <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK 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: 1 CERTIFY THAT IN THE PERFORMANCE OF THE vvonk FOR WHICH <br />THIS PERMIT 18 ISSUED HALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUB CONTRACTING SIGNATURE CERTIFIES <br />()MANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />HOURS IN ADVANCE FOR All. REOU/RED I PECTIONS AT 1200145S-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Title '''C 71. (TM 1y x7 <br />EC)C.(5k6 <br />3/ 0 /111I4Etr cAtAN (1 PARCEL SIZE/APNE <br />FOLLOWING: " <br />CALIFORNIA." T <br />Signed X <br />uct ,sit z6e PHONE /420V 1/65-'97/2_ <br />NOT PLAN 'Draw to Boatel Seale <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 />LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM on PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />S. LOCATION OF WELLS WTTHIN RADIUS OF ONE HUNDRED FIFTY FT <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />to <br />DEPARTMENT USE ONLY <br />ACCOUNTING ONLY: AIDE FACE <br />/ <br />PE CODES FEE INFO AMOUNT REMITTED KE/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />Li • 7 - q 7 C I 1 T g Ci - <br />---'-1--- <br />S Pk U0 " & 8 k-k c k <br />Pub. Health Serv. - Enviro. 173 (1/97) <br />Date <br />ADDRESS UCE PHONE E