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7j4/77 <br />Date V- f <br />-a <br />Area o 51. Application Acne/Tied By <br />Omni Inime•cilon BY Date <br />c;) <br />Pump Impaction By <br />Deetroction Iooce.,lIo fly 0_1 <br />Date <br />C-00 <br />DEPARTMENT USE ONLY <br />APPLICATION FOR WELL/PUMP PE <br />, JOAQUIN COUNTY PUBLIC HEALTH IlikICES <br />ENVIRONMENTAL HEALTH DIVISION <br />304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br />(209) 468-3420 <br />NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br />(Complete In TrinUwe, <br />APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE vans SAN <br />JOAOUIN COUNTY DEVELOPMENT TITLE. CHAPTER 9-1 1 1 5.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR APNE fiRCAO #2J' '3 Z/ CITY i re,c-ilt- C-04- PARCEL SIZE/APNE <br />OWNER'S NAME E912C0 ALIA/ '514/0/1/4 ADDRESS l77 Si;e.e aoks C7 1...yeerc11!e C4 PHONE IfeenV24Y -et?, ens <br />CONTRACTOR 6/", • fir -71)); /11,7 51-717.L. ADDRESS ?yr HOWE fum ,- „,,„,, at tic, 4454407 PHONE irs10 t3/ 3 -570C <br />TYPE OF WELL/PUMP: 0 NEW WELL <br />0 INSTALLATION <br /> 0 Now 0 Repair <br />(TYPE OF PUMP) <br />0 DESTRUCT ION: <br />0 OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL E 0 SOIL BORING <br />A INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br />0 INDUSTRIAL 0 OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASINO 0 <br />0 DOMESTIC/PRIVATE 0 GRAVEL PACK/812E TYPE OF CASING/STEEUPVC DIA. OF WELL CASINO <br />El PUBLIC/MUNICIPAL 0 DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br />0 IRRIGATION/AG 0 OTHER GROUT SEAL INSTALLED BY 1/"Aeloy",,-,f_ ... GROUT BRAND NAME r <br />0 MONITORING GROUT SEAL PUMPED: IA Yee 0 No CONCRETE PEDESTAL BY DRILLER: 0 Yee 0 No S <br />APPROX. DEPTH o 4.4er LOCKING CHESTER BOX/STOVE PIPE S <br />PROPOSED CONSTRUCTION/DR/LUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 0 xl-- et,i A <br />SUB CONTRACTOR 1/ PH ecilc, ADDRESS <br />LICE PHONE E <br />El REPLACEMENT WELL <br /> O MONITORING WELL <br /> o OTHER -e-er--/nee <br />0 WELL SYSTEM REPAIR <br /> O CROSS-CONNECT REPAIR <br /> O VAPOR EXTRACTION WELL <br />H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br />0 <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 JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br />THIS PER T IS ISSUED, 1 MAT L NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA. CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br />THE FOL WINO: I CERTIFY THAT IN THE PERFOI;NCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED. 1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CAL1FOR CANT MUST CA 24 HO IN ADVANCE FOR All. REQUIRED INSPECTIONS AT 12011) 48.111-11422. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Title O tL Thet/r7a--52 4.N,/ Date 5/.16 /97 ()loner, X <br /> <br />PLOT PLAN (Drew to Scale) Scale <br />NAMES or SIRE R ROADS NEAREST TO OR BOUNDING THE PROPERTY. <br />OUTLINE OF THE PERTY, GIVING DIMENSIONS AND NORTH DIRECTION. <br />T. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. <br />4. 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 TT <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />to <br />A, 13 ZVI,* <br />ACCOUNTING ONLY: AIDE FACE <br />FE CODES _ FEE INFO AMOUNT REMITTED effelill/CASH RECEIVED BY DATE <br />— <br />PERALLUSERVIC T NUMBER INVOICE <br />35o/ 3' - (”' — i).4--/C_s- Co <br />Pub. Health Health Serv. - Enviro. 173 (1/97)