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IIIAPPLICATION FOR WELLIPUMP PERMIT AN JOAQUIN COUNTY PUBLIC HEALTH SERVICE ENVIRONMENTAL HEALTH DIVISION P.O. BOX 3K 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 12091469-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1 115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOBADORESS/ORAPN#26700 S. Banta Road CIT( Tracy PARCEL SIZE/APN# 16 ac-rPs OWNER'9NAME_All Pure Chemical Co. ADDRESS 26700 S. Banta Road PHONE# 835-5424 CONTRACTORWa St F3azmat ADDRE993233 Fitzgerald LC,r554974 moNE/ 638-7276 SUR CONTRACTOR ADDRESS_ RanrhO Cordova LIC# PHONE# TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL MONTORINO WELL# 7 St 8 ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# ., ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL (TYPE OF PUMP) ❑ OUT-OF SEnVICE WELL ❑ GEOPHYSICAL WELL# SOIL BORING SPP attached ❑DESTRUCTION: Work plan INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM p DIA.OF WELL EXCAVATION 8—in- DIA.OF CONDUCTOR CASING O 8 ❑ DOMESTIC/PRIVATE C}�GRAVEL PACK/SIZE —In TYPE OF CASING/STEEL/PVC PVC DIA.OF WELL CASINO 2—inch p ❑ PUBLIC/MUNIC IPAL ❑DRIVEN DEPTI4 OF GROUT SEAL 8 1 f f SPECIFICATION — R GROUT SEAL C MONITORING IRRIGATION/AG ❑OTHER GROUT SEAL(PUMPED!11 BY gazma-t GROUT BRAND NAME Vaa Ne CONCRETES PEDESTAL BY DRILLER:Od❑YeNo 5 APPROX.DEPTH 23 L tt_ LOCKING CHESTER BOX/STOVE PIPE BOX S PROPOSED CONSTRUCTION/DAILUNG METHOD: MUD ROTARY AIR ROTARY X AUGER CABLE OTHER- ---I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN-8 COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIAe. A CANT MUGCALL 24 HOURS IN ADVANCE FOR ALL REQUIRED I BPECTIONO (2001468-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. Sloped X i � Thla / PLOT PLAN(Draw to%*to)Sc.le to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL 9Y9TFM On PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EX19TING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. ;...SEE;..ATTACHED.. . ........... ....' ....<.. ... .. . .... ..... .. . .. ... ..... DEPARTMENT VSE ONLY n ' Applieetbn Accepted By M^' �'� Date '� _/- O—A Impoellon By Date Pt P In.peetlon By 061. Omlf etlon Impaction Sy Due ACCOUNTING ONLY: AID# FAC# PE CODES FEE INTO AMOUNT REMITTED CMF K# A811 RECEIVED BY DAIJE PERMIT/SERVICE REQUEST NUMBER INVOICE Pub.Health Serv.-Enviro.173(3/96)