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CITY ) PARCEL SIZE/APN# I JOB ADDRESS/OR APN# „eft-4 2c. 12-N <br />" DIA. OF CONDUCTOR CASING <br />DIA. OF WELL CASING 2-- • <br /> Area Date Z2.„ <br />Date Destruction Inspection By <br />ACCOUNTING ONLY: AUDI FAC# <br />APPLICATION FOR WELLIPUMP PERMIT <br />11 JOAQUIN COUNTY PUBLIC HEALTH SERVIL <br />ENVIRONMENTAL HEALTH DIVISION <br />P 0 BOX 388, 445 N. SAN JOAQUIN ST„ STOCKTON, CA 95201-388 <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 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 JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />OWNER'S NAME Jc ToT ADDRESS :tiq 0 a- k-Lo ( PHONE # '235 C C /C4 <br />CONTRACTOR C1 2L 164-11.- 41, D :5;423)1( <br />SUB CONTRACTOR 5 <br />ADDRESS po3 afile_ rt '/' 414 IJC# PHONE #(4 5-6t. "-) <br />ADDRESS/' / 513(1"k/604 LIU), <br />4/ VC/ t <br />Fee <br />PHONE # -'7.57/ <br />'NEW WELL <br />El INSTALLATION <br />El New ID Repair <br />0 REPLACEMENT WELL <br />El WELL SYSTEM REPAIR <br />H.P. <br />0 MONITORING WELL # 0 OTHER <br />0 VAPOR EXTRACTION WELL # <br />FIRST WATER LEVEL 0 <br />(TYPE OF PUMP) <br />0 OUT-OF-SERVICE WELL GEOPHYSICAL WELL # El SOIL BORING 8 <br />0 DESTRUCTION: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF WELL EXCAVATION <br />TYPE OF CASING/STEEUPVC <br />DEPTH OF GROUT SEAL SPECIFICATION <br />GROUT SEAL INSTALLED BY ...C-1`47).),:7' GROUT BRAND NAME R‘T-71, trx-:fr <br />GROUT SEAL PUMPED: ID Yee 0 No CONCRETE PEDESTAL BY DRILLER: 0 Yee 0 No <br />LOCKING CHESTER BOX/STOVE PIPE <br /> AIR ROTARY JC AUGER CABLE OTHER <br />A <br />I 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 />THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br />REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOVVING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <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- UST CAL). 24 URS IN ADVANCE FOR AL). REQUIRED INSPECTIONS AT (209) 468-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Signed X J Title /(l.7 . t Date <br />4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />B. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />IL <br />PLOT PLAN (Draw to Scale) Scale " to <br />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 OF ALL EXISTING AND PROPOSED <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. <br />p t (if€11 <br />Comments: <br />DEC 0 2 1994 <br />ENVIRONMENTAL HEALT1 rrrr- <br />TYPE OF WELUPUMP: <br />CROSS-CONNECT REPAIR <br />DEPTH PUMP SET FT. <br />INTENDED USE <br />ID INDUSTRIAL <br />J2 DOMESTIC/PRIVATE <br />PUBLIC/MUNICIPAL <br />IRRIGATION/AG <br />MONITORING <br />APPROX. DEPTH <br />TYPE OF WELL <br />El OPEN BOTTOM <br />laGRAVEL PACK/SIZE <br />0 DRIVEN <br />0 OTHER <br />PROPOSED CONSTRUCTION/DRILUNO METHOD: MUD ROTARY <br />Application Accepted By 1/11 <br />Grout Inspection By Date -1491 Pump Inspection By Date <br />DEPARTMENT USE ONLY <br />PE CODES FEE INFO AMOUNT REMITTED CHECK/MASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />IlLOP V . : 5 - ' <br />. itOon't 3(1