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Cs, re,6324--/ <br /> <br /> <br />cr rpr V\tr5 <br /> <br />D,“ zt-•-• Ft, A 1- Pct <br />Dosiomilen helper:Son By D•to <br />I FACE AIDE ACCOUNTING ONLY: <br />DEPARTMENT USE ONLY <br />Minn, InoneetIon By <br />Applieetlen A000pted By <br />Grout Inopection By (./k7-,,r...4 Dote <br />C comm./11r <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 <br />NOWREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete In Trinkets) APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TfTLE, CHAPTER 9-1 115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES. ENVIRONMENTAL HEALTH DIVISION. <br />R JOB ADDRESS/OR APN/ 9 91 )0 ir k4.44 CITY I rekCy <br />OWNER'S NAME c R_) t <br />CONTRACTOR C p _ ADDRESS 5 2t.) 5,4 Lk; <br />SUB CONTRACTOR F4 t" 'J R). ViaLV14.4, f ik LDREV. E 1.1.1"6 Ir\CI LICE <br />PARCEL SIZEJAPNE <br />ADORERS LI 1,./ LI,V4/41,14L4(//lo krr PHONE <br />CANE 1"8 7-5-5 C'e <br />PHONE 0 717113 <br />TYPE OF WELL/PUMP: 0 NEW WELL <br />0 INSTALLATION <br />0 NowD Rowdy (TYPE OF PUMP) OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL <br />0 DESTRUCTION: <br />INTENDED USE TYPE OF WELL INDUSTRIAL 0 OPEN BOTTOM <br />Li DONIESTICREUVATE <br />0 GRAVEL PACK/SIZE PUBLIC/MUNICIPAL 0 DRIVEN IRRIGATION/AG r., OoTtlEn C . I be r ;r195 GROUT SEAL INSTALLED BY <br />tc.4,ITIrivV.1- ' 'I" ..,-L, GI MONITORING i•C "\ I GROUT SEAL PUMPED: 0 Yoe Dee APPROX. DEPTH 1...-<,- C-N r 4-- PROPOSED CONSTRUCTION/DRILUNG METHOD: MUD ROTARY <br />REPLACEMENT WELL O MONITORING WELL 0 <br />0 WELL SYSTEM REPAIR <br />O CROSS-CONNECT REPAIR H P. DEPTH PUMP SET FT. <br />CONSTRUCTION SPECIFICATIONS DIA. OF WELL EXCAVATION TYPE OF CASING/ST EEL/PVC DEPTH OF GROUT SEAL <br />OTHER VAPOR EXTRACTION WELL / FIRST WATER LEVEL <br />X SOIL norm] (9 )1 <br />DIA. OF CONDUCTOR CASINO DIA. OF WELL CASING SPECIFICATION GROUT BRAND NAME CONCRETE PEDESTAL BY DRILLER: 0 Yoe 0 Ne <br />A <br />0 2 <br />S LOCKING CHESTER BOX/STOVE PIPE AIR ROTARY AUGER CABLE OTHER <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR ticEmsro AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE VVORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORN/A.• CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: I CERTIFY THAT 04 THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA. THE A <br />Signed X <br />NT MUST CALL 24 HOURS IN ADVANCE FOR ALL RECKFRIET) INSPECTIONS AT 12011 4011-.1423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Title 65-e-0 16K: ‘‘' 5-1 Dote 2/0 <br />PLOT PLAN (Drew te Soodel Soak. to I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. OUTLINE OF THE mortnre, GIVING DIMENSIONS AND NORTH DIRECT/ON. DIMENSIONED OUTLINES ANT) LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. <br />LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM on PROPOSED EXPANSION OF SEWAGE DISPOSAL SYSTEMS. S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. ON THE PROPERTY on ADJOINING PROPERTY. <br />PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMSER INVOICE --,, <br />3 Col s 1 .• co sct 2- a tti • • Oa. , <br />Pub Health Serv. - Enviro. 173 (1/97)