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•. APPLICATION FOR WELLIPUMP PERMIT <br /> .AN JOAQUIN COUNTY PUBLIC HEALTH SERI <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201 88 <br /> (209) 468.3420 <br /> NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Comp6ta In biplic9t9) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT rTITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. /( WCrrf <br /> JOB ADDRESS/OR APN# C./ 'gRCY ��jeirF'VWY CITY L TH1, O P PARCEL S1ZE/APNI Zq 0 13( -1-7 <br /> OWNER'S NAME S :�76` I,QOfJ /pAQS Q64 -G S , V 5/0- <br /> DRESS <br /> RESS 1C f ,I ,p kt(Z- 189/0 <br /> CONTRACTOR �i�E'97t'�r('^�,a°i4 ADDRES6�Z �/�JL IJER!//NPit�i..�P' LIC# PHONE 19f3_101 ly <br /> SUBCONTRACTOR S���TR vM EX��O,e yT�o/V ADDRESS,23C5_ W16&, ?9MDZ. L1CI S/22C. Y PHONE#965-972 <br /> TYPE OF WELL/PUMP; ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# <br /> ❑ <br /> (TYPE OF PUMP) New 11 Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL p <br /> 11,OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING <br /> �J g <br /> DESTRUCTION: ( -5;ycx- <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D <br /> ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/BTEELJPVC DIA.OF WELL CASING D <br /> ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GRO I SEAL SPECIFICATION g <br /> ❑ IRRIGATION/AG! ❑OTHER GROUT :;EAL INSTALLED BY GROUT BRAND NAME E <br /> ElMONFTORING C 3) [,/Z-LG 5 GROUT SEAL PUMPED: ❑Y« [IN. CONCRETE PEDESTAL BY DRILLER:[1Y- ❑No S <br /> APPROX.DEPTH SO /��(o / !�L LOCKING CHESTER BOX/67OVE RPE S <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE 011/ER <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION 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 ISSUED,16HALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FO WING: 1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT 16 ISSUED,16HALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIF NIA.' T11E PruCANT MUST C 24"0718 IN ANCE FOR ALL REQUIRED INSPECTIONS wAT 12091404-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> 8lpned X Title�Y! • Det. ✓ /2—97 <br /> PLOT PLAN (Draw to Scale)Scale to <br /> 1. NAMES OF STREETS OR ROADS NEA T TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 9. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6. 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 /> �y <br /> 130 <br /> > . <br /> PPw. r� �] DEPARTMENT USE ONLY <br /> Appll—d—Accepted By 1 ((� -+Ci pate J' '�'� 1 Are- <br /> Grout Inspect)on By Dote Pump Inspactlon By Date <br /> u <br /> Deatrction Irnpectltl�on By 7[�. Dot. �, �i� 'C`� <br /> Comments: i ,� l�w, I`C() J� ( ��L7 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />