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<br />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 />APPLICATION FOR WELL/PUMP PERMIT
<br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES
<br />ENVIRONMENTAL HEALTH DIVISION
<br />"...10 OCT 23 PN I 5 C-604 EAST WEBER AVENUE, STOCKTON, CA 95202
<br />(209) 468-3420
<br />DON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED
<br />(Complete In Triplicate)
<br />APPLICATION 19 IIEFIE BY MADE TO THE SAN JOAQUIN 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 9-1115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION.
<br />JOB ADDRESS/OR APN0 9 ,4‘.? of,/ A v PARCEL SIZ CI" SK.4-
<br />+("C-ix,r1:4c, Krit it,C.:"c—c-i-c---14-P I, 37"
<br />OWNER'S NAME cl_d-1 te , ADDRESS 1-2.-.? .c e+ PHONE —
<br />CONTRACTOR A-Ail -4- i• C - ADDRESS p I e C uc, PHONE ;,-.2 5
<br />
<br />2 ,
<br />
<br />F, t
<br />SUS CONTRACTOR J,( ,-0-14..." ADDRESS AC,..t: _L 4/c/L- DC, i.e.; PHONE S gat- -1 y.- T-Acksit
<br />TYPE OF WELL/PUMP: V.1 NEW WELL 0 REPLACEMENT WELL bt, MONITORING WELL 0 I 0 OTHER
<br />El INSTALLATION 0 WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELLS
<br /> 0 New 0 Repel/ H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL
<br />(TYPE OF PUMPI
<br />0 OUT-OFSERVKE WELL 0 GEOPHYSICAL WELLS
<br />
<br />0 SOIL BORING
<br />0 DESTRUCTION:
<br />TYPE OF WELL CONSTRUCTION SPECIFICATIONS A
<br />0 OPEN BOTTOM DIA. OF WELL EXCAVATION e ,,,..,..., h.e.. DIA. OF CONDUCTOR CASING .i•odfrt /3
<br />XI GRAVEL PACK/SIZE .2/..) iy . TYPE OF CASING/STEEL/PVC1,41 C.._ •4:4;cj. L ,4) DIA. OF WELL CASING 02 IL( i 4.,3 co
<br />0 DRIVEN .574%-t-C.-UPTH OF GROUT SEAL / S--- . SPECIFICATION R
<br />72r /.4. G it5 <- GROUT BRAND NAME c IA, ._ k.- E 0 OTHER GROUT SEAL INSTALLED BY
<br />GROUT SEAL PUMPED: (XI Yee O N, CONCRETE PEDESTAL BY DRILLER:a Yee 0 No S
<br />S
<br />PROPOSED CONSTRUCTION/DIVLUNG METHOD: MUD ROTARY
<br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APEUCATION AND THAT THE WORK 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 memo, 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 WON( FOR WHICH THIS PERMIT 19 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF
<br />CALIFORNIA. HE APPUCANT MUST CAD. 24 N ADVANCE FOR ALL REQUIRED INSPECTIONS AT 120111 441-9423. COMPLETE DRAWING AT LOWER AREA PROVIDED.
<br />E. Title 4:0 "C c - 7 4 2 Signed X 4,47 Date /1)//' 5/7u
<br />J
<br />°
<br />8
<br />INTENDED USE
<br />INDUSTRIAL
<br />DOMESTIC/PRIVATE
<br />PUBLIC/MUNICIPAL
<br />.0 IRRIGATION/AO
<br />K.MONITORING
<br />APPROX. DEPTH af.S 11 - LOCKING CHESTER BOX/STOVE PIPE
<br />AIR ROTARY AUGER CABLE OTHER
<br />PLOT PLAN (dew to 94,810 Scale
<br />1, NAMES OF STREETS OR ROADS NEAREST TO on 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 />Application Aceepteel By
<br />Giout Inspection By
<br />DEPARTMENT USE ONLY
<br />DV, I I 10 1C/ Pump Inspection By
<br />Delo Arse
<br />Uk "">rt._,V.A_Cl•--\
<br />
<br />Owtruction Intmection By
<br />Commenty
<br />ACCOUNTING ONLY: AIDS FAC0
<br />PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER
<br />— _
<br />INVOICE
<br />N,
<br />35 0 I If .21,00 3162_ 4 142-11,. 5( 0 oqi-1 1 ob , _ (
<br />Pub Health Serv. Enviro. 173 (1/97)
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