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z iI ArrLIbRiln Lilrumr rrKmll SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES r. c ENVIRONMENTAL HEALTH DIVISION «, P 00 388, 445 N. SAN JOAQUIN ST, STOCKTON, MIM201.3811 (209( 458.3420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) APPLICATION IS HM BY MADE TO THE SAN JOAQUIN COUNTY MR A PERMIT TO CONSTRUCT ANWOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPUMCE WITH SAN JOAQUIN COUNTY DEVELOPMENT MU,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBUC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION- JOB ADDRESSNR APN* 641 E. Charter Way CITY Stookton PARCEL SRE./A owNFR•s NAME Yhalid Mahmood(gQ�ick N Save) ADORES, 641 E. Charter Way PHONE*464-2206 i CONTRACTOR Frontier Drilling ADDRESS 1730 Hammond Dr.uc*673504 R DNE,520-0452 TurlocktCa. SUBCOIRMI.7011 1'1 ADDRESS UCi PHONE I TYPE OF WELLA U . ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EJRRACTION WELL* JI ❑Nw❑Re w' H-P. DEPTH PUMP SET—FT. - FIRST WATER LEVEL O RYPE OF PVMPI - pp11 0OUT-0FSERVICE WELL ❑ GEOPHYSICAL WELL* � /� qJ SOIL BORING � 6 ❑DESTRUCTION: 1 i INTENDED ME TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 8.5 ' DIA.OF CONDUCTOR CASING D ❑ DOMESTICIWaVATE ❑GRAVEL PACKXV� TYPE OF CASING/STEELTVC4X; LE .OF WEIL CASING D ❑ PusucimUWCBPA TT❑11 DRIVEN DEPTH OF GROUT SEALECIFICATION R ❑ NOYGATIOWAG L OTHER GROUT SEAL INSTAI I ED BYOUT BRAND NAME E ❑ MONITORING ! GROUT SEAL PUMPED: ❑Y. ❑NoNCRETE PEDESTAL BY DRILLERL❑Yr ❑No S APPIOIL O®rH 45 f t LOCKING CHESTER WMITPIPE S PROPOSED CONSTIWCTIONRIWWNG METHOD: MUD ROTARY AIR ROTARY AUGE OTHER I HEREBY CERT"THAT 1 HAVE PREPARED THIS ARTilCATVDN AND THAT THE WORK WALL BE DONE IN ACCORDANCE WITH SAN QUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGUTATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR UCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I IFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHNL NOT EMPLOY PERSONS SUBJECT TO WORIOAAN't COMPENBATIGN LAWS OF CAUFORNIA.- CO CTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -I CERDFY THAT IN THE PERFORMANCE OF THE WORK FOR WHK]I THIS PERMIT IS ISSUED,I SHALL EMPLOY SONS SUBJECT TO WORKMAN'{COMPENSATION LAWS OF CAUFOIWIA''TTIIHI ANTTMMUST C HOW W ADVANCE FOR ALL REGUERED 1145 : "AT I]Oa14ta =. COM E DRAWING AT LOWER AREA PROVIDED. sl', X — � /� .�d / Tm. Driller Dae 4/27/98 T Irk.w GOY.(S..w to 1. NAMES OF STREETS OR TOADS NEAREST TO OR UNDING PROPERTY. 4. LOCO F HOUSE SEWAGE DISPOSAL SYSTEM OR PROFYISED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS NO DIRECTION. EXPAN F SEWAGE DISPOSAL SYSTEMS. _ 3. DIMENSIONED OUTLINES AND LOCATION OF ALL AND PROPOSED S. LOCA FWELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE OR ADJOINING PROPERTY. ......._i...... ............i.. .:.._................ n........... ......ti.. ..J.. .... �.. .... ..n�:.�.41.wti ...4.. �. Y�4T .0... ..b.:n.� �.. ........ DEPARTMENT DBE ONLY 7 APPRmtIon Accepted By •("� _ het` 7 Ar- O 7S� I •:y Grout Imp.oUon BY Det. H+no l,rpecdon BY Dote Dstrue .Inepr BY DY- I � Comma : ACCOUNTING ONLY: AID* FAG PE CODES FEE INFO AMOUNT REMITTED EC ASH RECEIVED BY DATE PERMIT _ E REQUEST NUMBER INVOICE