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C1Q 7 <br />.......... <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 />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 WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />JOAOUIN COUNTY DEVELOPMENT TITLE. CHAPTER 9-1 11 5.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES. ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR APN0 s4-9t F CITY PARCEL SIZE/APN0 <br />TYPE OF WELL/PUMP: kaZ NEW WELL (8.) O REPLACEMENT WELL <br /> <br />O MONITORING WELLS is OTHER Ger, f)p_cer; <br />0 INSTALLATION <br /> <br />O WELL SYSTEM REPAIR <br /> O CROSS-CONNECT REPAIR <br /> <br />O VAPOR EXTRACTION WELL I <br />0 New El Repair M.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0 <br />(TYPE OF PUMP) <br />0111-OF-SERVICE WELL <br /> <br />O GEOPHYSICAL WELLS <br /> <br />O SOIL BORING <br />0 DESTRUCTION! <br />rl+Da. <br />OWNER'S NAME j\k40 0Q.E. PcrizzLexklA ADDRESS 549 ç CAltP-f .714 'gawk-A c_k PHONE /I 2_09 --11-) 35 -2 750 <br />CONTRACTOR Ariek, ktc2A-e_c-AA k 14. c• • <br />SUB CONTRACTOR fr5c4i fwv ittowskt-t403- artM2611!) LI SCAN' IC/1- <br />/Are 6, <br />ADDRESS t-A1 r A raSlca...11 ucs <br />1 <br />en I PHONE 1/ 91 35 —0 .2.ao <br />399 SIneak Pt <br /> <br />ADDRESS Vet Lam.t tflearis ciSz.52. ucs (06 313(3C PHONE .112.0 41.- /11. ^3510 <br />INTENDED USE <br />INDUSTRIAL <br />DOMESTIC/PRIVATE <br />PUBUC/MUMCIPAL <br />El IRRIGATION/AG <br />1,4 MONITORING <br />APPROX. DEPTH Ca a <br />TYPE OF WELL CONSTRUCTION SPECIFICATIONS .4 <br />El OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING 0 <br />0 GRAVEL PACK/SIZE TYPE OF CASING/ST EEL/PVC DIA. OF WELL CASING 0 <br />51 DRIVEN DEPTH OF GROUT SEAL Ter A 1., ban* c.r. WELL-- SPECIFICATION a <br />El OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME li, 414 KJ Cr yuc...4A- E <br />GROUT SEAL PUMPED: Op Yea 0 No CONCRETE PEDESTAL BY DRILLER: 0 Yee ON. S <br />LOCKING CHESTER SOX/STOVE PIPE S <br />PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATION 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 UCENSED 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 CALIFORMA. CONTRACTORS HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING! ' I CERTIFY THAT IN THE PERFORMANCE OF THE WWI( FOR WHICH THIS PERMIT IS ISSUED. I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CAUFORMA.• THE APPUCANT MUST CALLURS IN ADVANCE FOR ALL REGUIRED INSPECTIONS AT (NMI 41111,1423. COMPLETE DRAWING AT LOWER AREA PROVIDED. 7 <br /> <br />,A Pelt- .1 I rz..A.)----f_i-t , iv (... <br />i 12-41 c) , S . C TM* tlrifacc-V a„Cl KI /Ar--1•rik — S-4 GivilSr Date <br />) <br />, a <br /> <br />PLOT PLAN (thew to Social Scala • to 301 <br />NAMES OF STREETS OR ROAD 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 />Stoned X <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 />........ <br />........ • • <br />.. . <br />.. . <br />DEPARTMENT USE ONLY <br />Application Accepted By '1'11 <br />- 411/, <br /> <br />- <br />Gaeta Inapectien By Pump Intocetion By <br /> <br />Oslo <br /> <br />Deetruction tnirpection By <br />Comments: <br /> <br />0.1. Date <br /> <br />ACCOUNTING ONLY: AIDS FACE <br />PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECEIVED BY DATE PERMIT/SERVICE REGUEST NUMBER INVOICE <br />.330 1 - 1361 ? el 1 0 1 --1» ,"- c214211/1. n 12i (1.5'., <br />Pub Health Serv. - Enviro. 173 (1/97)