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APPLICATION FOR WELLIPUMP PERMIT • SAN JOADUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON. CA 95201388 (209) 469.3420 MOR-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 WRIT SAN JOAQUIN COUNTY DEVELOPMENT n TITLE,CHAPTER 9.1 11 5.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. ,1 O 5 -Ba n t a -Road CIT-IG n 1n mr a C V PARCEL SIZE/APNf JOBADDRESSIORAPN#j67OWNER'S NAME ,1 11nChemical Co. ADDRESS 26700 S • 3anta Road n PHONES 335-5424 CONTRACTOR l� IT ^� 1' ADDRESS 3233 Fitzaerald LICA554774 PHONE I 633-7270 SUB CONTRACTOR ADDRESS..7 a T!/"1'T�l rO'.'l"' .V a UC* PHONE S TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL Q MONITORING WELL f 7 .'J ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL IF ✓ ❑New❑Repair H.P. DEPTH PUMP SET ' FT. ; FIRST WATER LEVEL O (TYPE OF PUMP) ' 7,, ❑ OLR-OFSERVICE WELL ❑ GEOPHYSICAL WELL* SOIL BORING ti oto I LL -�chew B ❑DESTRUCTION: work plan INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFIC A 110 NS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION Z�—T •.•1 DIA.OF CONDUCTOR CASING D 7C (� ❑ DOMESTIC/I`RIVATE GRAVEL PACK/SIZE 5-1=1 TYPE OF CASINO/STEEt1PVC I . DIA.OF WELL CASINO 2—inc n 0 ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL 3 — •! r t SPECIFICATION —T R 0 IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY .,i * GROUT BRAND NAME 0Ortl and E QMONITORING GROUT SEAL PUMPED: C3Yee Ne �•. CONCRETE PEDESTAL BY DRILLER:❑Yee U No S APPROX.DEPTH '7 Z =t- LOCKING CHESTER BOX/STOVE PIPE C:{ S PROPOSED CONSTRUCTIONIDRILLING METHOD: MUD ROTARY AIR ROTARY___X_AUGER CABLE OTHER I HEREBY CERTIFY THAT 1 IIAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN 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 19 ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'!COMPENSATION LAWS OF CAUFORNIA�.(/' THE AP{(PPUCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REGUIRED INSPECTIONS A7 1"01401113422. COMPLETE DRAWING AT LOWER AREA PROVIDED.. /� Slpned X '`•�/!r .i �G - /�J V i/�/`' Tltle �/(� '�- Dote .SII � Y PLOT PLAN IOrow to Soule)Boole 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, 3. DIMENSIONED OUTUNFS AND LOCATION OF ALL EXISTING 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. L .. .. ATT ACHED .1•'t ... .....y.. ......:... .... .. .. .. ....: ..:....... .. r ... ... DEPARTMENT USE ONLY Appllcetlon Amep(M By 9t �/t'V� `�\ ___Dot* �]! Are/-L/,e 4",S' C Grout I—Peetlon By Dote Pump Inmeetlen 8y Dete Deetruetlon tnepoctlo1Jn By Det. Cemmonte: W LIQ, LA 1 ACCOUNTING ONLY: AID* FAC! i PE CODES FEE INFO AMOUNT REMITTED CHECK*1CA8H RECEIVED By DATE PERMITMERVICE REQUEST NUMBER INVOICE 7 Z O l z Z 3;? ' f Pub.Health Serv.-Enviro.173(3/96)