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APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY F9ILA __ <br />JOAQUIN COUNTY DEVELOPMENT TITLE. CHAPTER 9-1 1 1 5.3 ND THE <br />JOB ADDRESS/OR APIV/i9gaT i4t/ 2 /1K../ 321/ A/. <br />OWNER'S NAME /MC° / rel ‘,/ 5.,.9 pie / <br />1-,%;, Or : #iy <br />/ <br /> / 4 5/ 7474. <br />SUB CONTRACTOR <br />CONTRACTOR <br />APPLICATION FOR WELL/PUMP PEF <br />S JOAQUIN COUNTY PUBLIC HEALTH S. ACES <br />ENVIRONMENTAL HEALTH DIVISION <br />304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br />(209) 468-3420 <br />c3,,q 71tt /1.7,0/01- NOR-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete In TrInlientsI <br />-PERMI TRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE W1111 SAN <br />AROSE OUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION, <br />CITY 572, rori . PARCEL SIZE/APNK <br />ADDRES133"0).Sli.ele e:22ta C-/-,1441,s77t.] <br /> <br />PHONE <br />ADDRESS gra #cave_ Apte E2 4 ICS 105./407 PHONE K (1-41.7%)—CPC7 <br />ADDRESS UCK <br />I <br />/ E <br />c) 7-cfR <br />PHONE <br />e- <br />INTENDED USE <br />INDUSTRIAL <br />CI DOMESTIC/PRIVATE <br />PUBLIC/MUNICIPAL <br />IRRIGATION/AG <br />MONITORING <br />APPROX. DEPTH Lf9 <br />TYPE OF WELL <br />0 OPEN BOTTOM <br />0 GRAVEL PACK/SIZE <br />0 DRIVEN <br />0 OTHER <br />Li <br />da. <br />F <br />TYPE OF WELIJPUMP: <br />(TYPE OF PUMP, <br />NEW WELL <br />INSTALLATION <br />0 Now 0 Repair <br />REPLACEMENT WELL <br />0 WELL SYSTEM REPAIR <br />H.P. <br />MONITORING WELL I <br />CROSS-CONNECT REPAIR <br />DEPTH PUMP SET FT <br />OTHER421/YP <br />VAPOR EXTRACTION WELL <br />FIRST WATER LEVEL <br />OUT-OF-SERVICE WELL <br /> O GEOPHYSICAL WELL <br /> <br />O SOIL BORING <br />0 DESTRUCTION: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF WELL EXCAVATION <br />TYPE OF CASING/STEELIPVC <br />DEPTH OF GROUT SEAL <br />GROUT SEAL PUMPED: FM Yea 0 No <br />LOCKING CHESTER BOX/STOVE PIPE <br />PROPOSED CONSTRUC11ON/DRILUNG METHOD: MUD ROTARY AIR ROTARY AUGER <br />DIA. OF CONDUCTOR CASINO <br /> <br />Ao?—) <br />DIA. OF WELL CASING <br />SPECIFICATION <br />CONCRETE PEDESTAL BY DRILLER: 0 Y.. O N. <br />GROUT SEAL INSTALLED BY 77-e-Kiltoti.C. /°0)/1-e- GROUT BRAND NAME <br /> CABLE OTHER 40,),e_c— e-s <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 VVORK FOR WHICH <br />THIS nun- IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUS-CONTRACTING SIGNATURE cenrinEs <br />THE OLLOWING: " I CERTIFY THAT IN THE PERFO ANCE OF THE WON( FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CALkNIA./11PPUCANT MUST CALL 24 NàI IN ADVANCE FOR AU. REWIRED INSPECTIONS AT 12011I 4554423, COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />e_e_ De <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 />Title Wt. <br />PLOT PLAN (Draw to Scale, Scala to <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 FIFTY FT. <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />/\<) <br />DEPARTMENT USE ONLY <br />Application Aconotori Fly Dote 7 —1 Are. <br />Grout InaroctIon By Dote Pump Inspection By Dote <br />OrAttroctIon InenorAlon Ay a <br />)11 s- 4- <br />Z <br /> / <br />ACCOUNTING ONLY: AIDS PACK <br />PE CODES FEE INFO AMOUNT REMITTED C.ITITC1)1/C ASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUIVIEIETI INVOICE <br />;-of <br />Erl .___ <br />3'1 Id 576, - 71 - r- <br />Pub. Health Serv. - Enviro. 173 (1/97) <br />Comment•: