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C FT- 3 1,0cou-fak Li:NA AU?. CAe,vor--,5 5 -6,4-e-7f- -6A04."- atdi.v_c_. 5 <br />C loccA leek ci" ) .400.0 <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 />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete In TripRental <br />APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH 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 pivirnoN. <br />(.4 > 0(.1A MCC <br />JOB ADDRESS/OR APNS ,j t - CITY ,r-1et4., PARCEL 80 <br />.,- OwNER .SNANIEc_;: ADDRESS - PHONE L 41 <br /> <br />I f <br />. CONTRACTOR 11 J.-1...J 1"-- C._ , ADDRESS pi r'--+5.4e...."" 0+ 9 t 1.51 UC ff PHONE -'4'2t 2-30 <br />SUB CONTRACTOR V;1:-- , , ADDRESS gilL'2111,4t5(-' <br />• <br />47 <br />SL ' <br />-C"LiC/ .L 2L2 PHONE c')./t. <br />to.:4 L <br />TYPE OF WELL/PUMP: 0 NEW WELL 0 REPLACEMENT WELL 0 MONITORING WELL 5 0 OTHER ?.....''--_,,.....- <br />0 INSTALLATION 0 WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELLS <br />El Now 0 Renee 1-1 P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0 e.---'—' <br />(TYPE OF PUMP)n. CO.- <br />0 OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELLS 1 <br />.14 SOIL BORING Li> ii.-- -it 2 t _ ' - 3 9 <br />0 DESTRUCTION: <br />TYPE OF WELL <br />0 OPEN BOTTOM <br />13 GRAVEL PACK/812E <br />0 DRIVEN <br />0 OTHER <br />INTENDED USE <br />INDUSTRIAL <br />DOMESTIC/PRIVATE <br />o PUBUC/MUNICIPAL <br />IRRIGATION/AG <br />MONITORING <br />APPROX. DEPTH <br />A <br />1 <br />DIA. OF CONDUCTOR CASINO <br />DIA. OF WELL CASING <br />SPECIFICATION R <br />GROUT SEAL INSTALLED BY e - TILe mtn, GROUT BRAND NAME E <br />GROUT SEAL PUMPED: 0 Y.. ON. CONCRETE PEDESTAL BY DRILLER: 0 Yea 0 Ne <br />LOCKING CHESTER BOX/STOVE PIPE 5 <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF WELL EXCAVATION <br />TYPE OF CASING/STEEUPVC <br />DEPTH OF GROUT SEAL <br />PROPOSED CONSTAUCTION/DRILUNO METHOD: MUD ROTARY <br /> <br />AIR ROTARY AUGER CABLE OTHER <br /> <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN 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 WORK FOR WHICH <br />THIS PERMIT 18 ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA. CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br />THE FOU.OWING: 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CAUFORNIA.' TIE APPUCANT MUST CALL 24 HOURS I ADVANCE FOR ALL REQUIRED INSPRCTIONS AT 12001 4014423. COMPLETE DRAWING AT LOWER AREA PROVIDED, <br />Stoned X Till. af #-Svs-Pc-- v 0.1. <br />A <br />PLOT PLAN (Drew to SoNel Scale • 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 /> <br />4, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />EXPANMON OF SEWAGE DISPOSAL SYSTEMS. <br />S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />DEPARTMENT USE ONLY <br />Application Accepted By 001/1 Area <br /> <br />0,00, In•Pectlen By, ) WAA.X..1 Z.11 or) CPT-3 Date Pump Inspection By Date <br />Dc•troction Inspection By tA.7...t./1A.A—ren."..._ .C7 ( 2.../C2C? C 1:1"-2__ <br />Comment,: <br />ACCOUNTING ONLY: AIDS FACE <br />PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH <br />3 CO I <br />RECEIVED BY DATE ,...---- <br />...„-- <br />POWIT/SERVICE REQUEST NUMBER <br />5f< 00z,act6,..) <br />INVOICE <br />, _ <br />Pub Health Serv. - Enviro. 173 (1/97)