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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 />APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WRII SAN
<br />JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1 1 1 5.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION.
<br />JOB ADDRESS/OR AF'N/ i 9 Q.: t- A.,)
<br />OWNER'S NAME ADDRESS
<br />CONTRACTOR CZ:4-4111 cs4.,,
<br />SUB CONTRACTOR Pc. 1
<br />TYPE OF WELL/PUMP:
<br />(TYPE OF PUMP)
<br />0 DESTRUCTION:
<br />NEW WELL
<br />0 INSTALLATION
<br />0 New 0 Repe4r
<br />CITY /-61- Al /Cc tcl • PARCEL StZEJ ,..),D '7 -24,4-, - 2/
<br />4,) z.,./-k--p.-:›-c... ,•:;-‹_.-4,..........,1, c • • '-- 74,0 5 PHONES C., "5- ) - TC-: C..
<br />7c .2c i,.:, i/ -,..) e.,4-,,,, .1,"Z, i 3 'i _,_,,,
<br />CA ‘istca... IJCS #,,'/.-itii- PHONES 424' --)
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<br /> n..)
<br />rine, 3 cif.) l.. •AAt./•1-1 . A...,(.. ( , 7 ._ (f;4? .. •,,,.....
<br />
<br />j,... i „a eA y se/6 i ucs:11,5_, .S( PHONE I../....4 y - Y.dri -c, -..„
<br />-,...
<br />.` \.
<br />ADDRESS
<br />REPLACEMENT WELL
<br />WELL SYSTEM REPAIR
<br />H.P.
<br />OUT-OF-StRVME WELL
<br />ADDRESS
<br />A MONITORING WELLS ale 4 0 OTHER
<br />CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELLS
<br />DEPTH PUMP SET FT. FIRST WATER LEVEL
<br />GEOPHYSICAL WELLS 0 SOIL BORING a c
<br />INTENDED USE
<br />INDUSTRIAL
<br />DOMESTIC/PRIVATE
<br />PUBLIC/MUNICIPAL
<br />1:1 IRRIGATION/AO
<br />likMONITORING
<br />APPROX. DEPTH
<br />CONSTRUCTION SPECIFICATIONS
<br />OM. OF WELL EXCAVATION e, ic.., IC: mx..t......
<br />GRAVEL PACK/SIZE iih.L54add/TYPE OF CASING/STEEL/PVC DV i'... .t".- k
<br />0 DRIVEN DEPTH OF GROUT SEAL P 4-c.1 (._:j ic_<.L.4 SPECIFICATION
<br />r .4, , I--,i3 GROUT SEAL INSTALLED BY .-77-1 c.r.-r,,..t. ....4 gyi.., 5 -4— GROUT BRAND NAME 4o.4, k
<br />GROUT SEAL PUMPED: I@ Yee 0 N. CONCRETE PEDESTAL BY DRILLER: El Yee 0 No
<br />
<br />LOCKING CHESTER BOX/STOVE PIPE 61:)1(..
<br /> AIR ROTARY AUGER ,..../.. CABLE OTHER
<br />TYPE OF WELL
<br />0 OPEN BOTTOM
<br />T)-‘ -Ts
<br />PROPOSED CONSTRUCTION/DRILUNG METHOD: MUD ROTARY
<br />A
<br />DIA. OF CONDUCTOR CASINO
<br />DIA. OF WELL CASING 2 ft) 4
<br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATMN AND THAT THE WOW 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 WOW FOR WHICH
<br />THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA. CONTRACTOR'S HIRING Oil SUB-CONTRACTING SIGNATURE CERTIFIES
<br />THE FOLLOWING: ' I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF
<br />CAUFORNIA." T APPLICANT MUST CALL 24 N ADVANCE FOR ALL REQUIRED INSPECTIONS AT 13001 4884423. COMPLETE DRAWING AT LOWER AREA PROVIDED.
<br />Maned X Date ii.)7/9A7t.;
<br />1
<br /> Title Pfc. *S89.
<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 />S < . ,A *.4
<br />DEPARTMENT USE ONLY
<br />Apollo:odor. Aceepted By
<br />(trout Impaction By
<br />OwtructIon InereelloR By
<br />Comments:
<br />16 oo Arso
<br /> Date Pump Inspection By
<br />
<br />ACCOUNTING ONLY: AID/ FACE
<br />PE CODES FEE INFO AMOUNT REMITTED CHECK/MASH RECEIVED BY DATE
<br />_
<br />TRIERVICE REQUEST NUMIIIR INVOICE
<br />31 40 (At lila/ S(< DO 7
<br />,
<br />,
<br />Pub Health Serv. - Enviro. 173 (1/97)
<br />PLOT PLAN (Drew to Rode) Seale
<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 or ALL EXISTING AND PROPOSED
<br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS.
<br />" to
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