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..... .. ... <br />, TCT `) -C H 9 <br />iLii <br />ACCOUNTING ONLY: AIDE FACE <br />PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECEIV t BY „, DATE 1 PERMIT/SERVICE REQUEST NUMBER INVOICE <br />.3 1)0 I SZ 9 0 c) I/I''qcf / <br />4 f- Lt. i 3/fici <br />v co sc ii7 <br />, <br />Pub Health Serv. Enviro. 173 (1/97) <br />DEPARTMENT USE ONLY <br />(Cl/ <br />Dote j „aliturnp Inspection By <br /> <br />ApplIcetten Aecepted By <br />Grote Inspection By <br /> <br />DoetroctIon Impaction By <br />Coremercv <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 />NOR-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete In 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 WITH SAN <br />JOAOUIN COUNTY DEVELOPMENT TITLE. CHAPTER 9-1116.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIMS , <br />JOB ADDRESS/OR AM, 34C 4 CITY PARCEL SIZEJAPN/ / -0 /0117/ <br />OWNER'S NAME L• '-L)V ADDRESS NO El t. <br />CONTRACTOR 44VC4 Et, V SlOt t.,Vtf .1 ( ADDRESS* I..; , uce pHoNE eZt:,IPC:1- c <br />ADDIVESSeelauk 3:4 2-4R.4.1411.1; UC/ le PHONE 1/114./C'S-11.;•:.‘ <br />5 <br />1+; -1 Wi t4'-c 0 OTHER <br />(TYPE (TYPE OF PUMP) <br />0 DESTRUCTION: <br />SUB CONTRACTORCI244`41‘%11 1 - <br />NEW WELL <br />INSTALLATION <br />0 New 0 Repelr <br />OUT-OF-SERVICE WELL <br />TYPE OF WELUPUMP: N MONITORING WELL REPLACEMENT WELL <br />WELL SYSTEM REPAIR CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELL 0 <br />DEPTH PUMP SET FT. FIRST WATER LEVEL <br />0 <br />GEOPHYSICAL WELLS <br /> <br />CK SOIL BORING '3 <br />TYPE OF WELL <br />0 OPEN BOTTOM <br />0 GRAVEL PACK/SIZE 4 2112- <br />El DRIVEN <br />0 OTHER <br />PROPOSED CONSTRUCT1ON/DRILUNG METHOD: MUD ROTARY <br />INTENDED USE <br />INDUSTRIAL <br />DOMESTIC/PRIVATE <br />0 PUBLIC/MUNICIPAL <br />IRRIGATION/AG <br />MONITORING <br />APPROX. DEPTH <br /> -23 <br />GROUT SEAL PUMPED: 0Y.. RN. <br />0C11-71—NO CHEST--;1710-;)STI OVE PIPE <br /> AIR ROTARY AUGER <br />A <br />DIA. OF CONDUCTOR CASING <br />. •11 DIA. OF WELL CASING 4... 0 <br />SPECIFICATION ig '-: k- O • ....-- LC 4 a I vi- St-I" CC. 101 R <br />GROUT BRAND NAME CC , i'l.k (:‘,.144 4....1, \---- E <br />CONCRETE PEDESTAL BY DRILLER:RI Yee 0 No S <br />CABLE OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF WELL EXCAVATION C •( <br />TYPE OF CASING/STEEL <br />DEPTH OF GROUT SEAL cte ,,a.4,,ko <br />GROUT SEAL INSTALLED BY <br />I ISEPEBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK IAALL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND <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 VVORK 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 PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORIOAAWS COMPENSATION LAWS OF <br />CAUFORNIA." THE APPUCT MU CAU. 24 HOURS IN ADVANCE FOR AU. REQUIRED INSPECTIONS AT 12011 41111,1423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Dote 4 l J ij Skirted X • frO tLc.iCk. tc1,11 At•J',/,,s14- - <br />PLOT PLAN (Drew to Rosie) Scale <br />. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. <br />. OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. <br />. DIMENSIONED OUTUNES AND LOCATION OF ALL EXISTING AND PROPOSED <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. <br />to <br />4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />IL LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />ON THE PROPERTY on ADJOINING PROPERTY.