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D f APPLICATION FOR WELL.IPUMP PERMIT mac . SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 t NOR-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED O POMPLY10EWIT (Complete ie 70plieete)AI'PLICATkON IS HERE$Y MADE TO THE 6AN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANblOR INSTALLTHE Wow DESCRIBED.THIS APPLfCATH)N 1 EH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SEfMcE8,ENVIRONMENTAL HEALTH DIVISION. �. BANTA R D . �t� CITY TRACY PARCEL SIZFIAPN, JOB ADDRESS/OR APFI, 835-4949 OWNER'S NAME MB0 PARTNERSHIP AOb11E8666a5 - W. DELTA AVE . TRACY ,,.,,,, 8 3 5--X 9 4 9 coNTRAc7GR'Irr.In1rnsr_ ROS .- DRING CO . INC .AODRES@3525 PELANDALE MOD Llc, 29U813PHONE, 545- 1185) ADDRESS-------,ucr PHONE■ .} SU$CONTRACTOR 7 (� I TYPETYPE OFWELUpUMp: C NEW WELL ❑ REPLACEMENT WELL ❑ MONrTORINO WELL, ❑ OTHER ❑ tNSTALLATION ❑ WELL SYSTEM REPAIR © CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL r U ©New❑Repel, H.P- DEPTH PUMP SEF FT. FIRST WATER LEVEL {TYPE OF PUMPI ❑ puT-OF•BERVICE WELL ❑ GEOPHYSICAL WELL r ❑ SOIL BORING 9 ❑DESTRUCTION: A INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFIC ATIONA r� OF WELL EXCAVATION 12 f 1 DIA.OF CONDUCTOR CASINO O ❑ INDUSTRIAL OPEN BOTTOM VIA. O ISI OOMESTICIf RiVATE rp,+GRAVEL PACKf@!ZE TYPE OF CASINGISTEEIJPVC P V C DIA-OF WELL CASINO �} PVSIrclMUNicipnl ❑DRIVEN SPECIFICATION B E N T O N I T E DEPTH OF GROUT SEAL 100 , ECIA Q ❑ IRRtDATIONIAG ❑OTHER GROUT BEAL INSTALLED��••$Y H E N N I N G S GROUT BRAND NAME e ❑ MONITORING GROUT SEAL PUMPED' 0 Yee ❑No CONCRETE PEDESTAL BY DRILLER:❑Yw LCT Ne S APPROX.X.DEPTLOCKING CHESTER BOXr@TOVE PIPE S [� ' H PROpoSED CONeTRUCTIOIT/DRILLINO METHOD: MUD ROTARY X AIR ROTARY AUGER CABLE OTHER; I HEQE$Y CERTIFY THAT t HAVE PREPARED THIS APPLICATION AND THAT THE WORK'An BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS.AND RULES AND REGULATIONS OF T14F SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:-1 CERTIFY THAT IN THE PERFORMANCE OF THE WOIIlC FOR WF,ICII Ti11S PERMIT IS ISSUED,i SHALLNOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S F41R1NO OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORIIMAN'e COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUR CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION*AT [ R 4413-3423. COMPLETE ORAWINO AT LOWER AREA PnOViDEO. 9-9-97 PLOT PLAN IDrew to 50e1e►@oele 'to 1. NAMES OF STREET@ OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. �- LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY.GIVING OIMENBION@ AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, 3. DIMERMONFO OUTLINES AND LOCATION Of ALL EXISTING AND PROPOSED 8. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STAUCIURES,iNCLUOWO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WALK ON THE PROPERTY OR ADJOINING PROPERTY. . ... :. .. ��. a W 9 - cn kA. a ,a r SEP 3 p LJ r r rNVff�pNArY=Nt7Z I'iSC,VlCES y�`'".AL7l.{fJllll�`fLr�Si _ .. 4 .,. .`.� .DEPARTMENT USE ONLY ..�.- - Y Ar..�_ f Drou1 in.pectbn By i -`Date/G7 31,, ° Pp(mpo O.n BY - Dete - Un•tnntlon tnepeetlen$ [ ` '- - te cemmn is: T ��c,et-rrvl,Ltl, ) rr?d,f Li e�F- c`r r�<,�rs.—L r-.t2-14 Gii1c� fF�TZ•�yut 't1 i lelN >� Cr�1 Clri+ t - 15<) Lt7rlr p�yC�Yi91JM� C.U•,I� � { �Lii/ Uw��-r� ��[rrLli� c�ljC?rr(-�!rr., c.v� ACC.UNTINII ONLY: AID, FAC, MR-L.I f I✓�<C �dr�� %� �r'`:f.- I.C).-`. PE CODES FEE INFO AMOUNT REMITTED CHECK,CASH RECEIVED BY DATF PERMITIbERVICE REQUEST NUMBER INVOICE S�3 [31 8a r Pub.Health Serv.-Enviro.173(1/97) 7//1