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F5' <br />_J <br />Grout Impaction By <br />Dolitrtictlen Impaction By <br />Commeot•: <br />/4 <br /> , <br />dy147 ,Ze -bce <br />Appllestlen Aece5144 By <br />A•to <br />Dela <br />DEPARTMENT USE ONLY <br />p Inimeoilon BY <br />APPLICATION FOR WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br />(209) 468-3420 <br />11011•REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Maniples In Triplicate) <br />APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/011 INSTALL THE VVOFIK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITII 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 APNI/ s•-•' (YR.._,TVAIC1/44L-A jt.ctry s#C)Cg- kloA PARCEL SIZE/APN/ <br />OWNER'S NAME S QVav st-Sk SC.,V•ACCi kIkAnfT (*ADDRESS 19 3 1 kJ-- £'Vt. PHONE /I <br />CONTRACTOR IA-VG tk - ADDRESS I. // \-)C,61" IJC/ PHONE, 57-1 L2-2-1 <br />RUB CONTRACTOR .0 ¼I ‘\••••V‘I ADDRESS • • Sco( S&'C uc.T2Cfl PHONE 1/7c3. 2,N-5 <br />TYPE OF WELL/PUMP: )5/7EVV WELL 0 REPLACEMENT WELL IWNIONITORJNG WELLS I 0 OTHER . N <br />0 INSTALLATION 0 VVELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELL S J 0 New 0 &weir H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0 <br />(TYPE OF PUMPI <br />0 OUT-OF-SERVICE WELL 0 GEOPHYSICAL VVELL <br /> <br />0 SOIL BORING <br /> <br />0 DESTRUCTION: <br /> <br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br />13 INDUSTRIAL 0 OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING .h./ 4 0 <br />0 DOMESTIC/PRIVATE 0 GRAVEL PACK/SIZE TYPE OF CASING/STEEUPVC u. <br />DIA. OF WELL CASING <br />2.. <br />0 0 PUBUC/MUNICIPAL 0 DRIVEN DEPTH OF GROUT SEAL (DE': SPECIFICATION 5 (. k ,,, . 'j ¼d A <br />0 IRRIGATION/AG HER GROUT SEAL INSTALLED BY •-kiMisVIs GROUT BRAND NAME VI-el:0(1A \ k/LeArm.... I. E <br />tirMONITOFIING GROUT SEAL PUMPED: kV« 0 No CONCRETE PEDESTAL BY MILER: 0 Yes ArNe 3' <br />APPROX. DEPTH 5 LOCKING CHESTER BOX/STOVE PIPE <br />PROPOSED CONSTRUCTION/DIBLUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLJCATION AND THAT THE WORK WILL BE DONE /N 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 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 WOW FOR WHICH THIS PERMIT IS ISSUED. I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CAUFORNIA.- THE APPUCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT MIMI 480-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Signed X QA4es-4.A-t Pe: . Title IS•ACX4,•.j-) <br /> <br />Dote 12-/2-cthg <br /> <br />PLOT PLAN (Drew to Soakil Scale <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, DRIVEVVAYS, AND WALKS. <br /> <br />10 <br /> <br />4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM on PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />I. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />9 BORING LOCATION / PROPOSED MONITORING WE LOCATION (MW-1) C7) <br />— <br />6 01 <br />• <br />ACCOUNTING ONLY: AIDS FAC I <br />PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH R 111Y ,, DATE PERMIT/SERVICE REQUEST NU ER MB INVOICE <br />— . <br />L7/ 2/Pi _ - ROC'l i :3 LH <br />1 , , <br />Pub Health Serv. - Enviro. 173 (1/97)