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APPLICATION FOR WELLIPUMP PERMIT O Y SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICESCD O ENVIRONMENTAL HEALTH DIVISION P.O. BOX %8, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 488-3420 LIA LeA�NON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ✓) ICBmpMH In TFiplkual APPLICATION 16 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION In MADE IN COMPLIANCE WRIT SAN JOAOUIN COUNTYDEVELOPMENT TITLE.CHAPTER ID-1116.3 ANO THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTII DIVISION. JOB AODRESS/OR APN/ S. W . Corner of Lehman/Hwy 33 CRY Tracy PARCEL SIZE/APN/ OWNER'S NAME—Banta-C a rbona Irri . Dist ADDRESS P . O . Box. 299 , Tracy PHONE/ 835-4670 CONTRACTOR Hennings Bros. Drilling Co. Inc. ADDnE683525 Pelandale Ave. LIC/ 290813 PHONE/545-1185 SUBCONTRACTOR ADDRESS LIC/ PHONE/ TYPE OF WELLIPUMP: R*NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL/ ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROS&CONNECT REPAIR ❑ VAPOR EXTRACTION WELL S (TYPE OF PUMP) 11 N.❑ReP.1, H P. DEPTH PUMP SET FT. FIRST WATER LEVEL G ❑ OUT-OF SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ BOIL BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL 111�1E OPEN Bottom DIA.OF WELL EXCAVATION 14 HI DIA.OF CONDUCTOR CASING D EI DOMESTIC/PNVATE LA GRAVEL PACKINZE TYPE OF CASING/STEELJPVC PUC DIA.OF WELL CASING 811 PC ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEM1I OF GROUT SEAL 10 0 1 SPECIFICATION BENTONITE R ❑ IMIOATION/AG ❑OTHER GROUT SEAL INSTALLEDBYH E N N I N O S GROUT BRAND NAME ,y, F ❑ MONITORING I p�` GROUT SEAL PUMPE01,4A,Y— ❑Ne CONCRETE PEDESTAL BY DNLLER:❑Y. In,,e 5 C� I APPROX.DEPTH V�U(/V\ LOCKING CHESTER SOXISTOVE PPE 5 AS PROPDSFD CONSTRUCTION/DRILLING MFT HOD: MUD ROTARY X X AIR ROTARY AUGER CABLE OTHER HFR Fly CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND TWAT TIIE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAGUIN COUNTY ORDINANCES,STATE LAWS.AND RULES ECAND C�C RULATIONB OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THIS FOLLOWING: 'I CERTIFY J14AT IN THE PERFORMANCE OF THE WOR(FOR WHICH' THIS PERMIT IB ISSUED,I SIIALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR BUB CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WORE(FOR WHICH THIS PERMIT IB ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE AN CAMT MUST CALL M POURS IN ADVANCE FOR ALL M(\OL"AGO INSPECTIONS AT 12"14004 23. COMPLETE DRAWTNO AT LOWER AMA PROVIDED. n SI. IX �`(V 0J if. D.I. 0CT. 8 , 1996 PLOT MN Mr.Ie Jel S 1. p IeT I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNCING THE PBDPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OB PFOPOSED 2, OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION EXPANSION OF BEWAOE DISPOSAL BYSTEMB. ]. DIMENSIONED OUTLINES AND LOCATION OP ALL EXISTING AND PROPOSED 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDGFO FIFTY FT. STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. / z P( 1A 41Z u :� ot OD1 � na, IIC. I I L, .i_i1. R i DEPERD,FNT USE ONLY APPlle.tlon Acce N l BY \ D.I. Y r, Pune Imewntlnn SY Drbuelb-- D.Ia 1 7 NIrP AIDI FAC/ OUNT REMITTED CHEC MAS" RECEIVED Ne DATE PERNITISFRVICE IIEOUEST NUMSER INVOICE 6 7Z �J 2 I