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DEPARTMENT USE ONLY <br /> Date <br />Date OPucno In•PcctiOn BY Date <br />APPLICATION FOR WELLIPUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 98201-388 <br />(209) 468 3420 <br />NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br />(Comptes in Triplicate <br />APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCFLIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />JOAQUIN COUNTY DEVELOPMENT Tv LE, CHAPTER 9 -1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR APNE --A.VA-13 C....ri Cr, ''--Scr_taci.. PARCEL SIZE/APNE <br />crA/144i6E eilEffin- <br /> <br />Cf 0 i-lx.-_,;-tuteS'elnes•cADDREs..52.13 .- ah 711.Ar_Ja4 GU S'171-AC)40NE , <br />CONTRACTORACLUApa rct GC.,13 j..,,,Ali ea.).,‘Ac.,,,,vivi ADDRESI LICE rilo zi? PT/ONE A Sto----0 zro(i <br />:FibeiSL-027(4/4./ <br />SUB CONTRACTOR 1:::)eci I ( ti"-Ae.. ADDRESS (797 z/ e PROS <br />TYPE OF WELL/PUMP, 0 NEW WELL <br /> <br />0 REPLACEMENT WELL <br /> CI MONITORING WELL :I <br />0 INSTALLATION 0 WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR <br />0 New 0 Roy.I H.P. DEPTH PUMP SET FT. <br />0 OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL E <br />0 DESTRUCTION: <br />(TYPE OF PUMP) <br />0 SOIL BORING <br />0 OTHER 151(61:›eiD rcle„_ <br />o VAPOR EXTRACTION WELL <br />FIRST WATER LEVEL <br />INTENDED USE TYPE OF WELT. <br />0 INDUSTRIAL DOPES BOTTOM <br />0 DOMESTIC/PISVATE 0 GRAVEL PACK/SIZE <br />0 PUBLIC/MUNICIPAL 0 DRIVEN <br />0 IRRIGATION/AG 0 OTHER <br />/2(MOMTORING <br />APPROX. DEPTH <br />PROPOSED CONSTRUCTION/DRILUNO METHOD MUD ROTARY <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF WELL EXCAVATION AN ( / • 1 ZC 4..) DIA. OF CONDUCTOR CASING <br />TYPE OF CASING/STEEL/PVC DIA. OF WELL CASING A.) /A D <br />DEPTH OF GROUT SEAL SPECIFICATION A <br />GROUT SEAL INSTALLED BY GROUT BRAND NAME ..4.4eAt3 \ot E <br />CONCRETE PEDESTAL BY DRILLER, 0Y.. Os. <br />OTHER ale/...,0/the_.. <br />A)/4 <br />AV *9 r <br />GROUT SEAL PUMPED: Dye. ON. <br />LOCKING CHESTER BOX/STOVE PIPE <br /> AIR ROTARY AUGER CABLE <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 />REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIER THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br />THIS PERMIT 18 ISSUED, 1 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 CALIFORNIA. THE AP CANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOUIRED INSPECTIONS AT 12091 4111-3421. COMPLETE DRAWING AT LOWER AREA PROVIDED. 24 <br />Signed X Aid a, ziiir Title .---.4cc.640/6,?.. ii....VIL Date 7-17- "Vs- ,...../ PLOT PLAN Drew to Seal& Scala ' 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 />4 -7*1211ic-4(.- <br />PAY ME N't <br />riFc,rmri <br />JUL 1 7 1995 <br />SAN JOACP do (y.: <br />PUBLIC HEALTH SERVICES <br />LNVIPONMENTAL HEALTH UfkilSicr <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 />Application Accepted 8 <br />Ototd Impection By <br />Daelmation Inapection By <br />Cornments• <br />Dee <br />ACCOUNTING ONLY: AIDE FACE <br />PE CODES FEE INFO AMOUNT REMITTED ICUICICASH RECEIVED BY DATE PERMIT/SERVICE <br />-,.. <br />REQUEST NUMBER, INVOICE <br />ISZ, ) WWI g --' 0 cc O 0 ci S.- 1 '71s-ri # / , „ <br />..56) (.• 0 <br />f--4°16t