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APPLICATION FOR WELL/PUMP PERRia <br />Sd OAQUIN COUNTY PUBLIC HEALTH SWICES <br />ENVIRONMENTAL HEALTH DIVISION <br />304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br />(209) 468-3420 <br />NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complei in Triplicate) <br />APPLICATION is HERE 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 />JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1 1 1 5.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION, <br />JOB ADDRESS/OR APNF e i-jArtat-SA- LC ;AU Cil" 5c-0 A Cqu, .01 C.c K CITY Shi. F4:201‘ PARCEL SIZE/APRo <br />OWNER'S NAME A • Za- • \ ,E,A1•1-fre- <br />CONTRACTOR cLs'411-," 6Airo, viOc. <br />SUB CONTRACTOR ‘) %J.*/ ••\ <br />TYPE OF WELL/PUMP: NEW WELL <br />0 INSTALLATION <br />0 New 0 Repolr <br />0 REPLACEMENT WELL <br />0 WELL SYSTEM REPAIR <br />H.P. <br />0 \J <br /> <br />4/ 3 ''MONITORING WELL If 0 OTHER <br />0 CROSS CONNECT REPAIR CI VAPOR EXTRACTION WELL I <br />DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> <br />(TYPE OF PUMP) CI OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL F <br /> <br />0 SOIL BORING <br /> <br />0 DESTRUCTION: <br /> <br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br />0 INDUSTRIAL 0 OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING 0 <br />0 DOMESTIC/PRIVATE 0 GRAVEL PACK/SIZE L Tyrt OF CASING/STEEL/PVC DIA. OF WELL CASINO - 0 <br />0 PUBLIC/MUNICIPAL 0 ono/EN DEPTH OF GROUT SEAL SPECIFICATION \/- tC R ft <br />0 IRRIGATION/AG <br />VMONITORING <br />0 OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME tt 13.4, ail, E r <br />GROUT SEAL PUMPED: MY... 0 No CONCRETE PEDESTAL BY DRILLER: 0Y.. tirNo <br />APPROX. DEPTH <br />LOCKING CHESTER BOX/STOVE PIPE <br />PROPOSED CONSTRUCT1ON/DRILUNG METHOD: MUD ROTARY_ AIR ROTARY AUGER CABLE OTHER <br />I HEBER'? CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WWI( WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND <br />REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br />THIS pFnuirr 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 WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CALIFORNIA.' THE APPUCANT MUST CALL 24 I4OURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 1201) 4513-2.423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />SIgnod X 4:7Y1A-611 <br />• <br /> Dote --"0 -/9is <br />PLOT PLAN (Draw to Soots) Seale 'to <br />I NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />OUTIINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, <br />DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS. DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br />AC <br />ADDRESS R M¼\}. A A PHONE 1 Z.- 3zu <br />ADDRESS ( SiC,8 i PHONE S 759 <br />ADDRESS Pc:1- 6 SIQ kksUCI41 CC PHONE (7O) 3-74 <br />5 (9 <br />BUILDING FORMER PUMPS <br />FORMER UST'S <br />SB6 <br />SB1/VW1 <br />AC <br />SB6/MW3 <br />09 SB3/VW2 <br />3B4/MW2 <br />SE32/MW1 <br />SB7 <br />OAK APPROXIMATE SCALE <br /> <br />_DEPARTMENT USE ONLY <br />/ • Dots <br />4 .e.• /((..: ('Th , Impaction i(pr <br /> v <br /> <br />Appllootlosi Aceoptod By <br />Grout Inopeciron By <br /> <br />Ares <br /> <br />11, <br /> <br />k <br /> <br />DoettoctIon Inspection By <br /> <br />Des <br /> <br />Commoto•• <br />ACCOUNTING ONLY: ONLY: AIDS _ EAU/ <br />PE CODES FEE INFO OUNT REMITTED CHECKS/CASH RECEIVED BY DATE T NUMBER INVOICE [ vii _, <br />ti241.. A - .7 t ' 0 .' <br />c <br />Pub. Health Serv. - Enviro. 173 (1/97) <br />c.ri\i_n • 30 0 30 FEET