Laserfiche WebLink
FY <br />tRifittoL <br />INTENDED USE TYPE OF WELL <br />INDUSTRIAL 0 OPEN BOTTOM <br />DOMESTIC/PRIVATE 0 GRAVEL PACK/SIZE <br />PUBUC/MUNICIPAL 0 DRIVEN <br />IRRIGATION/AG 0 OTHER <br />9 MONITORING <br />APPROX. DEPTH 10i <br />PROPOSED CONITRUCTIONfORILUNO METHOD: MUD ROTARY <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF WELL EXCAVATION <br />TYPE OF CASING/STEEL/PVC <br />DEPTH OF GROUT SEAL <br />GROUT SEAL INSTALLED BY-T-11.1 IAA GROUT BRAND NAME E <br />GROUT SEAL PUMPED: Ebro 0 No CONCRETE PEDESTAL BY MULLER: 0 Yoe 0 No 5 <br />LOCKING CHESTER BOX/STOVE PIPE LC, C.- <br />AIR ROTARY AUGER Y./..... CABLE OTHER <br />A <br />0 DIA. OF CONDUCTOR CASING <br /> -z <br />DIA. OF WELL CASING <br />SPECIFICATION <br />aW DEPARTMENT USE ONLY <br />AppllootIon AeeoPI.1 BY <br />Grout Iropectlor Si <br />DoetructIon Ir000ctloo BY <br />Comoro/or <br />loot:toe/Ion By Otto <br />,PPLICATION FOR WELL/PUMP PERM, <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 />ICamplete In 'Triplicate) <br />APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE VVORK DESCRIBED. THIS AF'PLICATION IS MAIDS IN COMPLIANCE W1111 SAN <br />JOAOUIN COUNTY DEVELOPMENT TITLE, CHAPTER 3-1115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SEEM ES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR APNS I LSO I. WA CITY /)4j PARCEL SIZE/AMC <br />— <br />OWNER'S NAME CO Ok 15- L.-L_ Ho if) ADDRESS 7, 2,1 1 t WIL.-(__\ kW PHONE , 4166.-Z4 <br />9.INTRACTOR P ADDRESS Z (-15 ,; (r UFO Z2t7 TylotiE <br />STS'cEckaTICF6‘LC-(1(cii Tr 1,-71- -ro 5T1 LL k3E,E:v.3t1, ADDRESS iz_jq. 1:)0442- MI Cl 752 pnoNE <br />Lot?) <br />TYPE OF WELIJPUMP: 0 NEW WELL <br />0 INSTALLATION <br />0 Now 0 Rover <br />REPLACEMENT WELL <br />WELL SYSTEM REPAIR <br />HP. <br />MONITORING WELLS <br />CROSS-CONNECT REPAIR <br />DEPTH PUMP SET Fr. <br />OTHER <br />VAPOR EXTRACTION WELL <br />FIRST WATER LEVEL <br /> <br />(TYPE OF PUMP) <br />O OUT-OF-SERVICE VTR!. 0 GEOPHYSICAL WELLS g. SOIL BORING <br />0 DESTRUCTION7 <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS AF'PUCATION 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 VVOPK FOR WHICH <br />THIS PERMIT 18 ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORMA." CONTRACTOR'S HIRING on SUB-CONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: ' 1 CERT THAT 4P1 THE PERFORMANCE OF THE VVORK FOR WHICH THIS PERMIT IS ISSUED. I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CAUFORNIA.• MU4 CALL UFT1I III ADVANCE FOR ALL REQUIRED INSPECT/OPTS AT 12041 4611.3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Title L <br />Storied X <br />Deo ?;/ I 2_ 7 Cl <br />PLOT PLAN PT.& to So•Tol SoAls • to <br />NAMES OF STREETS OR ROADS NEAREST TO OR B N(i1NG THE PROPERTY. <br />OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. <br />DIMENSIONED OUTLINES AM) LOCATION OF ALL EXISTING IMO PROPOSED <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. <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 />ACCOUNTING ONLY: AID/ PAC/ <br />PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH NEC ED BY DATE PEWIT/SERVICE RECIUEET NUMBED INVOICE <br />3561 3/5Y <br />0 <br />II <br />Pb LiaaLth San/ Pnyjrn 171 (1,971