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OWNER'S NAME <br />CONTRACTOR <br />lje...vev-- <br />A dvANcexi &ft awl (Na.-QA,4)1-1-).:1-Ax- - <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUtlINVit ltm. - <br />(Complete In TrIplleoto1 •11\-"\l ivIENT /Al ,-4` <br />JOB ADDRESS/OR APR/ -7 Ti 501,,r14 LtL if1 <br />`'`• <br />JOAOUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1 1 1 5.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL A <br />iT9 IL APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED. Tk.HIFIIM4AT/OSIMIZIpl..„ Ci WITH SAN <br />CITY 1%si p iti <br />AooRtes 771 sbc-rt, Let KsT sirrer PHONE ST) - <br />ADDRESS 14,-; wal UC. (CF-C27:1 PHONES 4-67 -icck. <br />PARCEL SIZE/APNO <br />SOIL BOrUNG <br /> ) <br />DIA. OF CONDUCTOR CASING <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 JUN 0 3 199 , <br />SUS CONTRACTOR ADDRESS UCS PHONES <br />TYPE OF WELL/PUMP: 0 NEW WELL <br />o INSTALLATION <br /> 0 New El Repelr <br />(TYPE OF PUMP) <br />REPLACEMENT WELL 0 MONITORING WELL <br />0 WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR <br />II.P. DEPTH PUMP SET <br />OTHER <br />VAPOR EXTRACTION WELL S <br />FT. FIRST WATER LEVEL <br />OUT-OF-SEFIVICE WELL 0 GEOPHYSICAL WELL F <br />IS‘3TRUCTION: <br /> 1=03 *• bard 0-% S <br />D'\,P <br />RC <br />GROUT BRAND NAME E .c.,,,, <br />CONCRETE PEDESTAL BY DRILLER: 0Y.. 0 No <br />c--- <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND -r <br />REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR UCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH (-- <br />THIS PERMIT 19 ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA. CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES r <br />THE FOLLOWING: " I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OP";-7, , \ CAUFORN1A." THE APPUCANT MUST pAti.4 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12011) 458-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Title eICE/C)/151/iiii fiVi <br />' <br />ii 2 fil Afila Dm. 000cl <br />.z0 ...I\ PLOT PLAN (Draw to &We) Scale i - 10 <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. <br />DIMENSIONED OUTUNES AND LOCATION OF ALL EXISTING AND PROPOSED <br />11, 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 />site pup ktKaied w; ocg.K PiAN) <br />... <br />INTENDED USE TYPE OF WELL <br />INDUSTRIAL 0 OPEN BOTTOM <br />DOMESTIC/PRIVATE 0 GRAVEL PACK/SIZE <br />PUSUCRAUNICIPAL 0 DRIVEN <br />IRRIGATION/AO 0 OTHER <br />MONITORING <br />APPROX. DEPTH 30 re,ir <br />PROPOSED CONSTRUCTION/DRILUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER V <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF WELL EXCAVATION <br />TYPE OF CASING/STEEUPVC <br />DEPTH OF GROUT SEAL <br />GROUT SEAL INSTALLED BY <br />GROUT SEAL PUMPED: 0 Yee 0 No <br />LOCKING CHESTER BOX/STOVE PIPE <br />DIA. OF WELL CASINO <br />SPECIFICATION <br />i <br />Maned X IC Al. <br />DEPARTMENT USE ONLY <br />Application Acceoted BY Ce.31A 1%.14401A.re1 <br />Orout Immolation By Det4, Pump Inopectlen By <br />Doetruction Inepectkm By <br />Comment•: <br />Date Oh () h A'" <br />Date <br />ACCOUNTING ONLY: AIDS FACF <br />PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />3 0 \ 4iS sz.c. 12335 TF ill 73 e,PC) 1 9 5'10 <br />Pub Health Serv. - Enviro. 173 (1/97)