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APPLICATION FOR WELL(PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> x; - ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201.388 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM OATS ISSUED <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBE,THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAUUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION- — & <br /> JDB kDDRESSroR APN# 5023 N. Flood Road CITY Linden PARCEL.. '# — <br /> - - <br /> OWNER'S NAME, <br /> RaTnacher Manufacturigg. _ADDRESS, 5023 N F'1 ooc� Road PHONE!f 209)887-3815 <br /> +I Gregg Drilling & -Testing, Inc. ADDRESS Martinez, CA ut,485165 PHONE# (510)313-5800 <br /> CONTRACTOR <br /> f ADDRESS LLC# PHONE# <br /> I! SUBCONTRACTOR <br /> ❑ OTHER <br /> TYPE O NIP. ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING NG ECT # ❑ VAPOR EXTRACTION WELL# J <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR © C1W55-CONNECT REPAIR <br /> Q Nev 1:1 Rmelr H-P. <br /> DEPTH PUMP ST Fr. FAST WATER LEVEL <br /> 1pI <br /> �(rypE OF PUMP) ❑ O�-Or-SERVICE WELL ❑ GEOPHYSICAL WELL# 4cF SOIL BORING a <br /> ©DESTRUCTION: <br /> TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS A <br /> INTQIOED USE D <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM <br /> DIA,OF WELL EXCAVATION DIA.OF CONDUCTOR CASING <br /> TYPE OF CASING/STEELlPVC PIA Of WELL CASING D <br /> ❑ DOMESTIClPPoVATE GRAVEL PACKISRZE -- R r <br /> ❑ pUBL1CIMUNICLPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> IRRIGATIONlAG OTHER <br /> GROUT SEAL INSTALLEO BY GROUT BRAND NAME E <br /> ❑ ❑ ' <br /> GROUT SEAL PUMPED- 13 Yea 11NoCONCRETE PEDESTAL BY DRILLER:13 Y— ❑Na S <br /> ❑ MONrTORING S <br /> APPROX.DEPTH LOCKING CHESTER BOXISTOVE PIPE <br /> rL <br /> t,, <br /> AUGER CABLE OTHER G2O—p>r'obe <br /> RLOPOSED CONSTRUCTIONMMLUP40 METHOD: MUD ROTARY AIR ROTARY V - <br /> 1 E HEREBY 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 Q <br /> E REGULATIONS OF THE SAN HAVE <br /> COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFYTHAT 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 W <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> + CALIFORNIA.' THE CANT M�C24URS INADVANCE FOR ALL REOUIRED INSPECTIONS AT("91 468-9423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> ,,(-1^1t\ �Pp� Titla i"a1.P 0 i� -- Date �4✓'�' r <br /> { PLOT PLAN(Drew to Seam)S"+% (�'to 46, . <br /> 1 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 1, NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE <br /> PROPERTY. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 2, OUTLINE OF THE PROPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. <br /> Ir 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S- LOCATION OF W1715 WITHIN RADIUS OF ONE HUNDRED FIFTY FT. l <br /> [ STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS,AND WALKS - -- - - <br /> 111111 <br /> N THE PROPERTY OR ADJOINING PROPERTY. <br /> ... - .. _- <br /> {`)jL A)f T i�J`p' <br /> 1 DEPARTMENT USE ONLY <br /> r <br /> Data Orn' / �• <br /> } Application Accepted By <br /> Grout Impaction By <br /> Date ( f �;Pump Impaction By Dote <br /> ' <br /> Date <br /> Da.trwticn Iropection By ^ <br /> Cpmntenta• �C <br /> ACCOUNTING ONLY: AIDO FAG " 1 <br /> PE CODES FEE INFO AMOUNT REMITTED (CASH RECEIVED BY DATE MWITISEHVICE REQUEST NUM0FR INVOICE <br /> cy 4 j L TL -7 041r 13 <br /> i <br />