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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 />SAN JOAOUIN cowry FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN
<br />CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION
<br />APPLICATION IS HERE BY MADE TO THE
<br />JOAOUIN COUNTY DEVELOPMENT TITLE.
<br />•
<br />crry ,444-, } je_c4, C4 PARCEL SIZE/APN2 07.- 2.6o - z i
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<br />ADDRESS re-coiv...." CA c.v./ 5" ? •- W...,o 5 PHONE 1 4,57— .F5E6
<br />RY2i) le.o I/ Ce../ t..... /04,9, 5.,, ay
<br />ADDRESS p/c.-F..m.., hm.,, 44 54/37,4 UCF PHONE F 92S- 91C ".c_.39c
<br />Ho, .,.,•-,0 oZ.c4- cl,Aze, .„ ADDRESS .0.4,4f--15-ivC Z i Cil- -7 -T 0 --) 1Jci/ 4E) 5 i i , c PHONE 2 a 4.3 -
<br />TYPE OF WELL/PUMP: NEW WELL
<br />N INSTALLATION
<br />0 New 0 Repolr
<br />(TYPE OF PUMPI
<br />REPLACEMENT WELL
<br />0 WELL SYSTEM REPAIR
<br />H.P.
<br />OUT-OF-SERVICE WELL
<br />MONITORING WELL 0
<br />El CROSS-CONNECT REPAIR
<br />DEPTH pumP SET FT.
<br />GEOPHYSICAL WELL 0
<br />OTHER /1) AS•
<br />VAPOR EXTRACTION WELL S j
<br />FIRST WATER LEVEL 0
<br />SOIL BORING
<br />CONSTRUCTION SPECIFICATIONS
<br />DIA. OF WELL EXCAVATION
<br />TYPE OF CASING/ST EEL/PVC
<br />DEPTH OF GROUT SEAL
<br />GROUT SEAL INSTALLED BY
<br />GROUT SEAL PUMPED: El Vow 0 Ne
<br />5. /I
<br />c
<br />.2 2
<br />LOCKING CHESTER BOX/STOVE PIPE
<br />.4
<br />DIA. OF CONDUCTOR CASINO
<br />GROUT BRAND NAME ICY-Lk
<br />•
<br />CONCRETE PEDESTAL BY DRILLER: DY.. 0 No
<br />.5
<br />DIA. OF WELL CASINO
<br />SPECIFICATION
<br />PROPOSED CONSTRUCTION(DRILUNG METHOD: MUD ROTARY AIR ROTARY AUGER ;.1( CABLE OTHER
<br />INTENDED USE
<br />INDUSTRIAL
<br />DOMESTIC/PRIVATE
<br />PUBLIC/MUNICIPAL
<br />TYPE OF WELL
<br />0 OPEN BOTTOM
<br />0 GRAVEL PACK/SIZE
<br />0 DRIVEN
<br />IRRIGATION/AG -MOTHER
<br />gi MONITORING -
<br />APPFIOX. DEPTH 2A
<br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND
<br />REGULATIONS OF THE SAN JOA01.11N 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, 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 WOW FOR WHICH THIS PERMIT 19 ISSUED, !SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF
<br />VANCE FOR ALL REQUIRED INSPECTIONS AT 120•1411114421. COMPLETE DRAWING AT LOWER AREA PROVIDED.
<br />'PIT KAN (Drew to Soo1o1 Scot.,
<br />1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY.
<br />Z. OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION.
<br />3. DIMENSIONED OUTLINES AND LOCATION OF Alt EXISTING AND PROPOSED
<br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALES.
<br />AppllootIon A.:mooted By
<br />Grout Impeettoo SY
<br />L4 N)1 A nACt",1.,t1
<br />t
<br />Delo Slir Ammo
<br />Dote A,1107 Pump Inspection By Date
<br />DoolructIon tnensetkort By D•to
<br />DEPARTMENT USE ONLY
<br />vAnk / 02-- C41)
<br />ACCOUNTING ONLY: AIDS FACII
<br />PE CODES FEE INFO AMOUNT REMITTED CHECK/MASH RECEIVED BY DATE _PERMIT/SEFIVICE REQUEST NUMBER ---- , INVOICE
<br />3 5—C7 I 00 3672__ q t -5f-c3oL/S-1-
<br />N
<br />_
<br />Pub Health Serv. - Enviro. 173 (1/97)
<br />CAUFORNIA.' THE APPUCANT MUST CALL 24 HOURS I
<br />Signed X ta-Fyi
<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 FT.
<br />ON THE PROPERTY OR ADJOINING PROPERTY.
<br />to
<br />JOB ADDRESS/OR APNF n
<br />OWNER'S NAME QL/t
<br />CONTRACTOR p Id
<br />kt./. /Du i e. /4 u,(
<br />/0—m, kck, 711
<br />c A
<br />SUB CONTRACTOR re-W lip<t
<br />TM* PC,..) (Li- (rL ir Z-.1,48/0 9- 2_
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