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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 />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Camplate hi Triplicate) <br />nertionnon IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE MIK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />JOAQUIN COUNTY DEVELOPMENT TfTLE, CHAPTER 9-1116.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR APNS .2- iy,---0-7) rz-0 CITY .7 -4V10-e)/ PARCEL 1312E/APNI <br />Om-ART NAME Th41- 7I j' "Pc 4-ty ,1541/-1/44.4 VDDRESS 247.57tri ^S <br />CONTRACTOR AA/14/twed(_• te"6„, UCI16714-"j) PHONE 0.4,122/ael, <br />SUB CONTRACTOR ADDRESS UCS PHONE <br />TYPE OF WELLPUMP: 0 NEW WELL 0 REPLACEMENT WELL ,,ErMONITORING WELL S 0 OTHER <br />0 INSTALLATION 0 WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELLS ..1 <br />0 New 0 Rep& H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0 <br />(TYPE OF PUMPI <br />0 OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL S ,OIL BOIUNG 8 <br />0 DESTRUCTION: <br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS / ih'' 0 INDUSTRIAL 0 OPEN BOTTOM DIA. OF WELL EXCAVATION 2' i / AP /:--, DIA. OF CONDUCTOR CASINO 11/4' a <br />DOMESTIC/PRIVATE 0 GRAVEL PACK/fla, t -3 TYPE OF CASING/STEEUPVC DIA. OF WELL CASINO 0 .... <br />PUBLIC/MUNICIPAL 0 onnierr DEPTH OF GROUT SEAL L7--,....<,-re._44,42- AL-SPECIFICATION R <br />IRRIGATION/AO 0 OTHER GROUT SEAL INSTALLED BY ..-47e47 -1?-1 GROUT BRAND NAME 174a+ e- iS24 -- E <br />,MONITORING GROUT SEAL PUMPED: DV.. gre. CONCRETE PEDESTAL BY OFUU_ER: 0 Yes ON. S <br />APPROX. DEPTH .45 f----•‘:--r LOCKING CHESTER BOX/STOVE PIPE S <br />PROPOSED CONSTRUCT1011/01111LUNO METHOD: MUD ROTARY AIR ROTARY AUGER Ve..' CABLE OTHER <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCOR0ANcE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND <br />REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR UCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br />THIS PERMIT 18 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 18 ISSUED, I RIAU EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CAUFORNIA.- THE ACANT MUST CALL 24 HOURS IN ADVANCE FOR AU. REQUIRED INSPECTIONS AT 120I1) 40111-11421. COMPLETE DRAWING AT LOWER AREA PROVIDED. zeia <br /> TIN* ifi7 ' i-S1-- Date ..../ 4°-57e/ <br />PLOT PLAN (Drew to Seidel Scale to <br />I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL mow on PROPOSED <br />OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATKIS, DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br />Shined X <br />DEPARTMENT USE ONLY <br />Date 6/ 7 <br />Dote <br />..... . . . <br />Grout Impaction By e'ece-C."1?-\47.-6g-?Es <br />ApplicatIon Accepted By AAAfel PN <br />Destruction Impaction By <br /> LAJ"-E-J2, "(1'25 -1 c1 4/C" <br />RiLiferi <br />ow. <br />Purnp Inspection By <br />Comment.: <br />ACCOUNTING ONLY: AIDS PACS <br />PE CODES FEE INTO AMOUNT REMITTED CHEC‘KNICASH RECEIVED BY DATE PERMIT/SERV10E REQUEST NUMBER INVOICE <br />(if /9-) z. <br />(/2z) SA_' <br />Pub Health Serv. - Enviro. 173 (1/97)