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0 DOMESIIC/PRIVATE 0 GRAVEL PACK/SIZE <br />0 PUBLIC/MUNICIPAL 0 DRIVEN <br />1PPLICATION FOR WELL/PUMP PER <br />SA. JAIDUIN COUNTY PUBLIC HEALTH SVE.CES <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 />(Complete in Triplicate) <br />APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/On INSTALL THE WORK DESCRIBED THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />JOAOUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR AMA 5 03 EAsr TENTH S TREET clry TRACY PARCEL SIZE/APNA 235-19-13 <br />OWNER'S NAME CouNTY OF SAN TOAQuikt ADDRESS 211 <br />ADDRESS 399 HE <br />Es.W:BER AV E 6 T H F LOOR <br />srocToN, CA -7.02. CONTRACTOR F I S CH NY IRot4 ME L. k 9S NTA <br />PHONE (2.09)468-1010 <br />I ,s PLACE ucitt 6C8-3 513 2-5 mortro(209)442-3540 <br />vALLEY SPRING-5,CA SUB CONTRACTOR ADDRESS 9 52.5 2. uct PHONES <br />TYPE OF WELL/PUMP: 0 NEW WELL <br />0 INSTALLATION <br />0 Now 0 Repel/ <br />(TYPE OF PUMP! <br />IA DESTRUCTION: <br />0 REPLACEMENT WELL <br /> CI MONITORING WELL I o WELL SYSTEM REPAIR <br /> <br />0 CROSS-CONNECT REPAIR <br />H.P. DEPTH PUMP SET FT. <br />0 OUT-OF-SERVICE WELL El GEOPNYSICAL WELL <br />III OTHER GEOPRoBE <br />0 VAPOR EXTRACTION WELL <br />FIRST WATER LEVEL 0 <br />0 SOIL BORING <br />INTENDED USE TYPE OF WEU. CONSTRUCTION SPECIFICATIONS A CI INDUSTRIAL 0 OPEN norrore <br /> <br />NA o <br />NA <br /> <br />NA El IRRIGATION/AG 0 OTHER GROUT SEAL INSTALLED BY CoNTRACTOR GROUT BRAND NAME ._ <br />E 0 MONITORING GROUT SEAL PUMPED: III Yee D No CONCRETE PEDESTAL BY DRILLER: 0 Yoe 111 No s <br />APPROX. DEPTH 20 FT. LOCKING CHESTER BOX/STOVE PIPE NA s <br />PROPOSED CONSTRUCTION/DRILUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER CrEOPR0BE Soft AND G-ROUNDWATER GRAB SAMPLING./ SAME-DAY ABANDoNmENT <br />I HEnERY CERTIFY THAT I HAVE PREPARED THIS APPUCATION AND THAT THE WOW 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: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <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 />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 14OURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 120111451-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Slorwd X .1 \..../..„......KL —lel A ...e._ TItIo CONSVLTAKI T / AG-EN T 0.1, 10129191- <br />TosEPH RAMA,CrE PLOT PLAN ra (Drew to Seol Scale • to <br />I. 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, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM on PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS, <br />S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY LI- <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />AT A S ITE LA <br />DEPARTMENT USE ONLY <br />Applicotlen Aeo.sted ey <br />Dots Area <br />(1,o.,1Irxpowtlen By Dote RJmo Inspection By Dots <br />OnortoctIon Inennealo7 By <br />VW; 11-,kv,14, et <br />Dote <br />(465 t. 1-61 J,2)_ D00 lc Me' i 115 <br />ACCOUNTING ONLY: AIDS rAct <br />PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASHRECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />I cx.c- -74l_2t, t2.1‘,-ei 7 b _ .....,,w , . <br />._ <br />k---) 0 t 4 j (i/6p <br />Pub. Health Serv. - Enviro. 173 (1/97) <br />TYPE OF CASING/STEEL/PVC <br /> N A <br />DIA. OF WELL CASING <br />DEPTH OF GROUT SEAL TOTAL DEPTI-1 <br />DIA. OF WELL EXCAVATION 2- int. DIA. OF CONDUCTOR CASING <br />SPECIFICATION