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<br />APPLICATION FOR WELLIPUMP PERMI"
<br />P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201-341A Y 2 0 1999
<br />r SAN JOAQUIN COUNTY PUBLIC HEALTH SER...iS
<br />ENVIRONMENTAL HEALTH DIVISION
<br />(209) 468.3420
<br />(
<br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED
<br /> :.-.NViqo,,,,\/mEN MI HFALT1-1
<br />(Complete In Triplicate) PC:RMIT i c: c:pvi ,t- -,
<br />APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED. THIS APPLICATION IS MADE IN COMPLLANCE VVIT II SAN
<br />JOAOUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9 -1115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION.
<br />JOB ADDRESS/OR APNE i 4/ di 41 iV,A.C4..1 ec,-.F., Ma..),AJL-- cfre STOCK.M.1 PARCEL SIZE/APNE
<br />OWNER'S NAME UK) i"-E-t -I -"k4)-3 744-S , J Ai C ADDRESS 1i3-3 2:-,qt/ 020 ,1
<br />7,...,7 k, .D.,,irMa*FloNE <303)67/./-/32 "'Deo vela co 90159 CONTRACTOR V C; i.) --.0(1,1L-(-Jar M1DRESS"pct , 84c s....7 zo te,f );.-4.. IJCEr c-7- 72:39‘)/14-10NE /059 371/ •-lii c
<br />SUB CONTRACTOR CA-)6-e-e-----ce 4.- k-7,-,.....a, ADDRESS '3 Lis.° ),,,it,....,t- LICE PHONE S
<br />TYPE OF WELL/PUMP: 74 NEW WELL
<br />0 INSTALLATION
<br /> 0 New El Repair
<br />(TYPE OF PUMP'
<br />El REPLACEMENT WELL
<br />0 WELL SYSTEM REPAIR
<br />H.P.
<br />14...MONITORINO WELL sipapYl-N)T 0 OTHER
<br />0 CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELL
<br />DEPTH PUMP SET FT.
<br />./
<br />0 FIRST WATER LEVEL
<br />
<br />El OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL 1/
<br />
<br />0 SOIL ammo
<br />
<br />0 DESTRUCTION:
<br />
<br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A
<br />0 INDUSTRIAL 0 OPEN BOTTOM DIA. OF WELL EXCAVATION g DIA. or CONDUCTOR CASINO AM- D
<br />0 DOMESTIC/PRIVATE GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC PVC- DIA. OF WELL CASING Z., li it
<br />0 PUBLIC/MUNICIPAL 0 DRIVEN DEPTH OF GROUT SEAL 31', - , S 5- 1 SPECIFICATION 5c_il ii,L3 R
<br />0 IRRIGATION/AG 0 OTHER GROUT SEAL INSTALLED BY Dtt L.L.E-4., GROUT BRAND NAME E
<br />ticMONITORING GROUT SEAL PUMPED: VrYea O N.. CONCRETE PEDESTAL BY DRILLER: 0 Y... ON.. s
<br />APPROX. DEPTH te2 --- r) ig-S- ' LOCKING CHESTER BOX/STOVE PIPE s
<br />PROPOSED CONSTRUCTION/DRILUNG METHOD: MUD ROTARY AIR ROTARY AUGER K CABLE OTHER
<br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE VVOFV( WILL RE 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 TI1E WOW FOR WHICH
<br />THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA? CONTRACTOR'S HnNo OR SUB CONTRACTING SIGNATURE CERTIFIES
<br />THE FOLLOWING: I CERTIFY T IN T PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF
<br />CAUFORNIA.• THE ST C 24 HOURS IN ADVANCE FOR jLJ. REOLNRED INSPECTIONS AT 12051 4511-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED.
<br />41f/(464- -/esiz 0/3
<br />A." A A Stoned X
<br />PLOT PLAN (Drew to Scale) Scale
<br />NAME 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 WITHIN RADIUS OF ONE HUNDRED rirrv FT.
<br />ON THE PROPERTY OR ADJOINING PROPERTY.
<br />to
<br />DEPARTMENT USE ONLY
<br />Applicalion Acceptor, By
<br />Date
<br />DormoctIon Inspection By a ea_ tut. )- 11 ( Cis)
<br />7/ 11-Cm 5-tt4.-9.1 4 /01 kedi 71--ve
<br />ACCOUNTING ONLY: AIDS FACE
<br />PE CODES FEE INFO AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE
<br />8-C1 gel — e4,17y eo
<br />S 12 6.0 1 '5 2—g O
<br />Pub. Health Serv. - Enviro. 173 (3/96)
<br />Grout ImpectIon By ,-7) 4)-ciq imuq(ci (0 Pump InapectIon By
<br />Dale
<br /> o
<br />Comments:
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