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CROSS-CONNECT REPAIR* WI IA) 0 VAPOR EXTRACTION WELL I
<br />0 FIRST WATER LEVEL DEPTH PUMP SET FT.
<br />0.1. S" Pump Inapection By (r,(- ----
<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 Triplicate)
<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 WITH SAN
<br />JOAQUIN COUNTY DEVELOPMENT TITLE. CHAPTER 9-1 1 15.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION.
<br />JOB ADDRESS/OR APNE ii qta, J. I LA), e- err( PARCEL SIZE/APela „2.24 -2 44: - 2i
<br />ADDRESS 77,--tfr1c...)17
<br />4,- ALI er,"
<br />ADDRESS pi e.„4-3,+,„...tc,....) (4,0- eity .1‘..,,LICI
<br />,N.)l 0.-L-4C(
<br />
<br />ADDRESS_4f_t=hu,,,,.L.2.,.L2ur..,i_), IJCO 114)l Ci 77
<br />OWNER'S NAME Ce"...ti..IL A-e.-6-1,-c, •
<br />CONTRACTOR (- p tr- C I
<br />•
<br />SUB CONTRACTOR L. . -e.j)
<br />PHONE • • i 2
<br />(14 C.
<br />PHONE F - • --
<br />,L )
<br />yi NEW WELL 0 REPLACEMENT WELL
<br />.g INSTALLATION 0 WELL SYSTEM REPAIR
<br />New 0 Repair H.P.
<br />0 OUT-OF-SERVICE WELL
<br />CONSTRUCTION SPECIFICATIONS ,
<br />DIA. OF WELL EXCAVATION 7- j r....• L.c,-...S DIA. OF CONDUCTOR CASINO
<br />TYPE OF CASING/STEEL/PVC 1-)1/ 4,!.., - 'St Lt.
<br />DEPTH OF GROUT SEAL (..., 3 .4-'
<br />GROUT SEAL SEAL INSTALLED BY 77.--t.•_'..-I,121, ..e• /„..,_•,e GROUT BRAND NAME t'l • . Lek- E
<br />GROUT SEAL PUMPED: illy. ON. CONCRETE PEDESTAL BY DRILLER: laYse0 No s
<br />LOCKING CHESTER BOX/STOVE PIPE iL,.), s
<br />Th
<br />4. 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 />TROT PLAN (Drew to Boatel Scale • to
<br />I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE morthr-v.
<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 />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APFIJCATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN 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 WOW FOR WHICH
<br />THIS PERMIT IS ISSUED. 1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.• CONTRACTOR'S HIRING on SUS-CONTRACTING SIGNATURE CERTIFIES
<br />THE FOLLOWING: • I 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 />AD ANCE FOR ALL REGUIRED INSPECTIONS AT 12001 441111.1422. COMPLETE DRAWING AT LOWER AREA PROVIDED.
<br />•
<br />Title /2- 3# 2. Date
<br />CAUFORNIA.* THE A CANT MUST CALL 24 HO !LI
<br />Signed X
<br />DEPARTMENT USE ONLY
<br />Deetroction Inspection By
<br />Comment*:
<br />Date
<br />Application Accepted By
<br />Grout Inapection By
<br />Inirt,14"et,41,1 Date 71-- Ai..
<br />Dale
<br />ACCOUNTING ONLY: AIDS FACE _ _ L
<br />PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECEIVED SY OAT --KIM-IT/SERVICE REQUEST NUMBER ----- ---. INVOICE
<br />.35271 ,.. , co A.0 3'
<br />..._
<br />Pub Health Serv. - Enviro. 173 (1/97)
<br />INTENDED USE
<br />INDUSTRIAL
<br />DOMESTIC/PRIVATE
<br />PI/RUC/MUNICIPAL
<br />IRRIGATION/AG
<br />JA MONITORING
<br />APPROX. DEPTH -7 S
<br />PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY t," AIR ROTARY AUGER CABLE OTHER
<br />DIA. OF WELL CASING
<br />SPECIFICATION
<br />PHONE )-
<br />TYPE OF YVELUPUMP:
<br />(TYPE OF PUMPI
<br />MONITORING WELL • H..41. 0 OTHER
<br />GEOPHYSICAL WELL • 0 SOIL BORING
<br />TYPE OF WELL
<br />0 OPEN eorroki
<br />gi GRAVEL PACK/SIZE
<br />0 DRIVEN
<br />0 OTHER
<br />A
<br />0
<br />ht.A1
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