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SUB CONTRACTOR <br />ADDRESS UCE PHONES <br />(TYPE OF PITMPI <br />OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL <br /> a SOIL BORING 13 <br />REPLACEMENT WELL <br />0 WELL SYSTEM REPAIR <br /> 0 CROSS-CONNECT REPAIR <br />H.P. DEPTH PUMP SET FT. <br />0 VAPOR EXTRACTION WELLS <br />FIRST WATER LEVEL <br />911 MONITORING WELLS I V 0 OTHER TYPE OF WELL/PUMP: O NEW WELL <br />INSTALLATION <br />New 0 Repels <br />... .... . <br />DEPARTMENT USE ONLY <br />Pump Inspection By <br />OK* 11 (100 Are* <br />Dots <br />Dots <br />APPLICATIONN 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 />(Comple(e la Triplicate) <br />APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOFK DESCRIBED. TIPS APPLICATION 18 MADE IN COMPLIANCE WITH SAN <br />JOAOUIN COUNTY DEVELOPMENT TITLE. CHAPTER 9-1 115.3 AND THE STANDARDS OF SAN JOAOU1N COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR APNE t 5 /14 <br /> <br />R Or) 4 crry 5 1 t' %,14 Io,n <br />PARCEL SIZE/APN/ <br />OWNER'S NAME POV !V Z- ADDRESS PHONES <br />CONTRACTOR AC/ IT; (.2 r e el An 71- ii - ADDRESS 1 ///,' 0/4 yuc, 6 qC .2 2- 7 PHONE 46 7' /co <br />0 DESTRUCTION: <br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br />INDUSTRIAL 0 OPEN BOTTOM DIA. OF WELL EXCAVATION (..ii f i t & <br />0 DOMESTIC/PRIVATE rzi GRAVEL PACK/SIZE -" / 4 tl TYPE OF CASING/STEEUPVC <br />DEPTH OF GROUT SEAL / / - El PUBLIC/MUNICIPAL 0 DRIVEN <br />IRRIGATION/AG 0 OTHER GROUT SEAL INSTALLED BY .1 ,,,, 4 'Ti 441 4, <br />1/4 MONITORING GROUT SEAL PUMPED: 111 Yea ON. <br />APPROX. DEPTH 6 5 LOCKING CHESTER BOX/STOVE PIPE <br />PROPOSED CONSTRUCTION/DRILUNG METHOD: MUD ROTARY AIR ROTARY AUGER X <br />A <br />DIA. OF CONDUCTOR CASINO <br />71 <br />DIA. OF WELL CASINO <br />SPECIFICATION k 4-4 <br />GROUT BRAND NAME 14. <br />E <br />CONCRETE PEDESTAL BY DRILLER: 0Y.. OW. 3' X <br />CABLE OTHER <br />!HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATION AND THAT THE VY0FIK. 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 PERFORMANCE OF THE WORK FOR WHICH <br />THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORINA.• CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: I CERTIFY THAT IN THE PERFORMANCE OF THE WOPK FOR WHICH THIS PERMIT 19 ISSUED. I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS 0 <br />CALIFORNIA." THE APPUCANT MUST CAUL 24 HOURS IN ADVANCE FOR AU. REQUIRED INSPECTIONS AT 12011 411193423, COMPLETE DRAWING AT LOWER AREA PROmEo. <br />Signed X .//‘ /444 7/1A%ii-21 Title ?aff 6 ,zoto.9 Dots - I 7 cl <br />PLOT PLAN 113sew to Eloolol cools <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 OUTUNFS AND LOCATION OF ALL EXISTING AND PROPOSED <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. <br />4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />S. LOCATION OF WELLS WITHIN • OF ONE HUNDRED FIFTY FT. <br />ON THE PROPERTY OR ADJO <br />to <br />/4,01041110n Asee01,4 BY Let>044C°1" <br />Grout Impaction By ANAAAA-C <br />Ormtmetlan Impecllort By <br />Comment•: <br />ACCOUNTING ONLY: AIDE FACE <br />PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECEIVED SY PERMIT/SERVICE REQUEST NUMBER INVOICE <br />3 s--0 1 1 c-ci , 0 b 13 .24, Ci-e <br />1327 <br />1 t er 5R00?,15S< <br />Pub Health Serv. - Enviro. 173 (1/97)