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APPLICATION FOR WELL/PUMP PERMIT <br />SA. oAOUIN COUNTY PUBLIC HEALTH SE ;ES <br />ENVIRONMENTAL HEALTH DIVISION <br />304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br />(209) 468-3420 <br />NONREFUNDABLE 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/OR INSTALL THE WOW DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />JOAOUIN COUNTY DEVELOPMENT TfTLE, CHAPTER 9-1 1 1 5.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR APNE -10t- MU' CITY PARCEL SIZE/APNE <br />OWNER'S NAME girre--/-41 ADDRESS 12-C A/ PHONE 97-- 9'& <br />TYPE OF WELL/PUMP: VIEW WELL <br />0 INSTALLATION <br />0 New 0 Repair <br />(TYPE OF PUMPI <br />El DESTRUCTION: <br />El REPLACEMENT WELL 0 MONITORING WELL if <br />El WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR <br />H.P. DEPTH PUMP SET FT. <br />0 OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL <br />El OTHER <br />0 VAPOR EXTRACTION WELL / <br />FIRST WATER LEVEL <br />W"<oTt nonmo <br />...--- CONSTRUCTION SPECIFICATIONS , -w-r <br />DIA. OF WELL EXCAVATION ?6I <br />TYPE OF CASING/STEEV, <br />DEPTH OF GROUT SEAL E4/1 .14 <br />GROUT SEAL INSTALLED BY J(' <br />GROUT SEAL PUMPED: 0 Yee 0 No <br /> <br />LOCKING ESTE BOX/STOVE P7 <br />PROPOSED CONSTRUCTION/DRILUNG METHOD: MUD ROTARY AIR ROTARY AUGER <br />I HERESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN 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 WOW 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 WOW FOR WHICH THIS PERMIT IS ISSUED. I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CALIFORNIA - THE PLICANT MUST CA 24 U RS IN ADVANCE FOR AU, REQUIRED INSPECTIONS AT 120111 411111-34211. COMPLETE DRAWING AT LOWER AREA PROVIDED. 1,01./ LL <br />PLOT PLAN (Draw to Seale! Seale to <br />NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. <br />OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION, <br />T. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WAI.X8. <br />4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM on Pronosro <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />S. LOCATION OF WELLS Wf71-IIN RADIUS OF ONE HUNDRED FIFTY FT. <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />(9C69-7 <br />CONTRACTOR /716-7--j" <br />UB CONTRACTOR <br />ADDRESS A.-) <br />S <br />—ICJC7P" 2A-ItC <br />1•"4/4/-4--74.(,) e.ae-zr Apag*--.3 tica-2-06 tONE f s-- 7'9/ <br />INTENDED USE <br />INDUSTRIAL <br />El DOMESTIC/PRIVATE <br />PUBLIC/MUNICIPAL <br />IRRIGATION/AG <br />0.40NITORING <br />APP110 516' X. DEPTH <br />TYPE OF WEIJ. <br />El OPEN BOTTOM <br />I./RAVEL PACK/SIZE <br />0 DRIVEN <br />0 OTHER <br />A <br />DIA. OF CONDUCTOR CASING <br />fT <br />DIA. OF WELL CASING <br /> 2." <br />IT <br />...41-PECIFICATION <br />GROW' BRAND NAME —Pcs-r <br />CONCRETE PEDESTAL BY DRILLER: 0 Yee 0 No <br />CABLE <br />OTHER <br />Stun., X Title er fd Cfi <br />. .. <br />spc.FWEr <br />PAIMEN. <br />JUL V1998 <br />S/5,11 stUkt..1 114 QUI.11\11't <br />PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTItI Dtyts1 <br />DEPARTMENT USE ONLY <br />AnolleatIon Accented By 19717t C>rtitAn.e Del. <br />Are.Area <br />impr,ctIon By 4.,\‘ Cot—s Date 2-0( I C{Pump Inspection By Dela <br />flo•Intellon know:110n FlY Data <br />Comments, <br />ACCOUNTING ONLY: AIDE <br />_ <br />FACE <br />PE CODES FEE INFO AMOUNT R TED CHECKE/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />233 5 1,-161. 0 1 ki 1- 1- _ <br />SA006\11 <br />Pub. Health Serv. - Enviro. 173 (1/97)