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ORIGINAL <br />APPLICATION FOR WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />304 EAST WEBER AVENUE, STOCICrON, 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 JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN <br />JOAQUIN COUNTY DEVELOPMENT TITLE. CHAPTER 9-1116.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBUC HEA TH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR AF'NS / 7q Al. "rib .1--uh K b(. <br />TYPE OF YVELUPUMP: 0 NEW WELL <br />0 INSTALLATION <br />0 Now 0 Repair <br />REPLACEMENT WELL <br />(TYPE OF PUMP) <br />SOIL BORING OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL <br />d PARCEL SIZVAPNII CITY <br />PHONE I lid ADDRESS <br />*3 <br />Savdt <br />TYPE OF WELL <br />0 OPEN BOTTOM <br />jaGRAVEL PACK/SIZE <br />0 DRIVEN <br />0 OTHER <br />25 ' <br />if <br />INTENDED USE <br />INDUSTRIAL <br />DOMESTIC/PRIVATE <br />o PUBUC/MUNICIPAL <br />IRRIGATION/AG <br />X MONITORING <br />APPROX. DEPTH <br />Iv/A DIA. OF CONDUCTOR CASINO <br />005/7 e <br />OWNER'S NAME <br />ADDRESS qeos Ai. w , lc,. 14 / 4y u., 66 O2.27 ,,,..E , q0-1414C CONTRACTOR Alibian ed Geo& Ate <br />0 DESTRUCTION. <br />A holy Zclik KrAti; ADDRESS P. 6.0x <br />SUE CONTRACTOR <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF WELL EXCAVATION - II C <br />TYPE OF CASING/STEELO PVC <br />DEPTH OF GROUT SEAL .)1.4 41( -1-0 <br />GROUT SEAL INSTALLED BY T ' c Ni, e GROUT BRAND NAME 10 4' ( + I Ax d <br />GROUT SEAL PUMPED: lidjul 0 No CONCRETE PEDESTAL BY DRILLE110&•• 0 N. <br />LOCKING CHESTER BOX/STOVE PIPE 1/4'14 lofo( <br /> AIR ROTARY AUGER X CABLE OTHER PROPOSED CONSTRUCT1ON/DITILUNG METHOD: MUD ROTARY <br />I IIEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION ANT) THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES. STATE LAWS. AND RULES ANEr <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 ITURJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA. CONTRACTOR'S HIRING on SUS-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 INSPECT° T 12051 4115-3421. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />A 01 ci) •• S -f <br />Storted X gited•Zt-ei TIN. Dot. 3 -/ <br />DEPARTMENT USE ONLY <br />Apolloollon Arreepted By Dote A. Obg-e7e <br />Grout Inopectleo By <br />Dootructlen Inopecilou By <br />Commottio: <br />ACCOUNTING ONLY: AIDS FACS <br />PE CODES FEE INFOAMOUNT <br />kw) <br />REMITTED CHECK/MASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />35o t 2? 111Y-(8- ON-±A. ., <br />_ Lo 0 1 8-,s-2. <br />Pub Health Serv. - Enviro. 173 (1/97) <br />PLOT PLAN (Mow to Boole) S.I. • to <br />NAMES OF STREETS OR ROADS NEAREST TO OR ROUNDING 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 />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 />ONITORING WELL I <br />Dots Pump ImpeotIon By <br />I 0 PHONE 3vi-63q1 <br />0 WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR <br />H.P. DEPTH PUMP SET FT. <br />OTHER <br />VAPOR EXTRACTION WELL <br />FIRST WATER LEVEL 0 <br />A <br />DIA. OF WELL CASING - C <br />SPECIFICATION Sc L c--((.41r