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APPLICATION FOR WELLIPUMP PERMIT 1
<br />,AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES
<br />ENVIRONMENTAL HEALTH DIVISION
<br />P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201-388
<br />(209) 468-3420
<br />NON-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 JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1 1 1 5.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION i 3;i-
<br />JOB ADDRESS/OR APNS /(2/f 444i I I 011.1.4,-t - 4. 44.-eh 6,-e CITY„,V.Z1,-,-4e-,t PARC EL,SIZEJAPN0 ‘..-) /673° 03
<br />C.,
<br />OWNER'S NAME 14.-_(044.7ad6rAli eles/14L- ADDRESS /022_0 ..0 , /4„,, owt,t,z,_ „4 c.. 1.3. ke(/....„....t /s44 rve7.7 PHONE7071_ -77-77/
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<br />44
<br />ADDRESS 7,174‘,` 1.,121a0!_l)e, 1 S I, Ac, ,i. 7va, L PHONE
<br />..” 4. e,....,e' -4/.`trc-, `11-76 _cc/ ,Y,{0-cii'S c2r1/3 -imp ADDRESS ?1.19
<br />CONTRACTOR --77—Ceire`42467 ‘,
<br />SUB CONTRACTOR
<br />0 NEW WELL 0 REPLACEMENT WELL 13 MONITORING WELL # CI OTHER o INSTALLATION 0 WELL SYSTEM REPAIR 1:1 CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELL
<br />0 New 0 Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL
<br />0 OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL # SOIL BORING
<br />TYPE OF WELL/PUMP:
<br />(TYPE OF PUMP)
<br />DESTRUCTION:
<br />\ A
<br />D
<br />INDUSTRIAL 0 OPEN BOTTOM
<br />DOMESTIC/PRIVATE 0 GRAVEL PACK/SIZE
<br />El PUBLIC/MUNICIPAL 0 DRIVEN
<br />IRRIGATION/AG 0 OTHER
<br />MONITORING
<br />APPROX. DEPTH 3 5-
<br />DIA. OF WELL EXCAVATION I. c— (l-k , DIA. OF CONDUCTOR CASINO
<br />TYPE OF CASING/STEEUPVC DIA. OF WELL CASING
<br />DEPTH OF GROUT SEAL -
<br />GROUT SEAL INSTALLED BY 61N-ell IV , ll I 5-, GROUT BRAND NAME Cif- //0....,,,16,..
<br />GROUT SEAL PUMPED: 0 Y..
<br />D i 7)
<br />CONCRETE PEDESTAL BY DRILLER: D v.. 0 No
<br />LOCKING CHESTER BOX/STOVE PIPE
<br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS
<br />PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE 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: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH
<br />THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING on SUB-CONTRACTING SIGNATURE CERTIFIES
<br />THE FOLLOWING: I CERTIFY THAT IN THE PERFORMANCE OF THE WOR( FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF
<br />CALIFORNI HE A 'ANT MUST CALL 24 HOURS IN ADVANCE FOR AU. REQUIRED INSPECTIONS AT ?OS) 511-3423. COMPLET DRAVVINC Al 0.;.iier, AREA PROVIDED.
<br />Signed X /""fri Title S44 (-IL S9 19 Date
<br />PLOT PLAN (Draw to Seals) Soils to
<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 OR PROPOSED
<br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS.
<br />S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT
<br />ON THE PROPERTY OR ADJOINING PROPERTY.
<br />6<:.)
<br />
<br />DEPARTMENT USE ONLY
<br /> Date Chh 9 Application Accepted By 16‘1'44
<br />Grout Impaction BY Date / e)1 Pump Inspect)o ,n
<br />Arsi- 0A) n?(Lt
<br />Dote
<br />Destruction Inspection By Date
<br />Comments:
<br />ACCOUNTING °NIA AIDS FACS
<br />,
<br />10 4) 0 t'). /
<br />PE CODES FEE INFO AMOUNT REMITTED CHE46/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE
<br />t;> 0 /7 74 /*/g— th/r.
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