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CONTRACTOR 4 atirev)( 4-= Crc_ oz2) ADDRESS 4COS A) • L61/1 14(1 'MO &27 27 <br />SUB CONTRACTOR ADDRESS _57-7otri4a„..) <br />PARCEL SIZEJAPNI/ <br />OWNER'S NAME SYCD-7 G7..."- ADDRESS TC.16 PHONES ?3 -2,s1, <br />JOB ADDRESS/OR IPN Lit 3S nhiv-coi <br />JOAOUIN COUNTY DEVELOPME LE. <br />47. APPLICATION 19 HERE BY MADE THE <br />(209) 468-3420 <br />11011•REFUNDARE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED jERNAIT / <br />(Complete Is Triplicate, <br />SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WTTII SAN <br />CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY poem HEALTH SERVICES, ENVIRONMENTAL HEALTH ohnstoN. <br />PHONE # ‘274..2 2 <br />PHONE S <br />(TYPE OF PUMP, <br />0 DESTRUCTION: <br />REPLACEMENT WELL <br />0 WELL SYSTEM REPAIR <br />H.P. <br />OUT-OF-SERVICE WELL <br />J21-1.410NROFUNG WELL <br />CROSS-CONNECT REPAIR <br />DEPTH PUMP SET FT. <br />GEOPHYSICAL WELL # <br />OTHER <br />VAPOR EXTRACTION WELL I <br />FIRST WATER LEVEL <br />øsoit norirNo <br />TYPE OF YVELL/PUMP:, 0 NEW WELL <br />0 INSTALLATION <br /> 0 New 0 Repel/ <br />CABLE OTHER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF WELL EXCAVATION <br />TYPE OF CASING/STEE <br />DEPTH OF GROUT SEAL <br />GROUT SEAL INSTALLED BY <br />GROUT SEAL PUMPED: 0Y.. <br />LOCKING CHESTER CHESTER BOX/STOVE PIPE <br />AIR ROTARY AUGER <br />A <br />DIA. OF CONDUCTOR CASING <br />01*. OF OF WELL CASING fl 1:1 <br />SPECIFICATION <br />OFIOUT BRAND NAME <br />CONCRETE PEDESTAL BY DRILLER: 0Y.. 0 No <br />S <br />7-72veTz_6n6 <br />INTENDED USE <br />INDUSTRIAL <br />DOMESTIC/PRIVATE <br />o PUBUC/MUNIC1PAL <br />IRRIGATION/AG <br />_MONITORING <br />APPROX. DEPTH <br />TYPE OF WELL <br />0 OPEN BOTTOM <br />0 GRAVEL PACK/SIZE <br />0 DRIVEN <br />0157THER <br />)0 <br />11 3 <br />PROPOSED CONSTRUCT1ON/DIELUNG METHOD: MUD ROTARY <br />0 =_ <br />CP <br />D„,. ./C) 0 731. <br />Delo Pump Impaction By <br />Dote 3/, le 70-i <br /> <br />Application Accepted BY <br />Grout In.pection By <br />Do.utectlen Impaction By <br />Comment.: <br />I 5 5 c)-1.-'1" 2 u"). ),1,trl <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 />co° 00),Qcy <br />APR 06 '1999 <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATION AND THAT THE WOW 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 PERTORNIANCE OF THE WOW FOR WHICH <br />THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA. CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: ' I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF, <br />CAUFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED 1NSPEC PIS AT 12001 4•11-1.4211. COMPLETE DRAWING AT LOWER AREA 1/11) <br /> This rict/Cc) o.ty ? <br />_ <br />PLOT PLAN 1113row to Spolo) Seale '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 />Slurved X <br />. : ....... <br />DEPARTMENT USE ONLY <br />ACCOUNTING ONLY: AIDE EACO <br />PE CODES AMOUNT REMITTED CHECKS/CASH RECBVED BY DATE PERMIT/SEFIVICE REQUEST NUNS INVOICE <br />5-° I <br />FEE INFIX <br />- <br />(e/)? (C <br />) Z, / C:b 7 ez /°/`,/q 7 ,--)- 0 7 s-S- _ <br />\ <br />_ <br />e 6 0 2,61 S 5 <br />Pub Health Serv. - Enviro. 173 (1/97)