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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION W P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 4883420 / �/ NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ` j L KA__t F9 IGmPMU in TrIpSB[t61 APPLICATION IB HERE BY MADE TO THE BAN JOAMIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRBED.THIS APPLICATION IB MADE IN COMPLIANCE WITH BAN "AMIN COUNTY DEVELOPMENT TITLE,CHAPTER 81115.3 AND THE STANDARDS OF BAN JOAMIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDREBBKIR APNE S.11 . Corner of Lehman/Hwy 33 CITY Tracy PARCEL SIZE/APNO OWNER'SNAME Banta-Carbona Irri . Dist. ADDRESS P .O. Box. 299 , Tracy PHONE, 835-4670 CONTRACTOR Hennings Bros. Drilling Co. Inc. ADDRESS 3525 Pelandale Ave. L.C, 290813 MIGNE,545-1185 SUB CONTRACTOR ADDRESS UCO PHONE O TYPE OF WELIJPUMP: KNEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL O ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL O J ❑ N.❑R.•Ir H.P. DEPTH RUMP SET-FT. FIRST WATER LEVEL O RYPE OF PUMP) ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ SOIL BOPoNG B ❑DESTRUCTION! INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A A� 0pT INDUSTRIAL 0 OPEN BOTTOM DIA.OF WELL EXCAVATION 141I DIA.OF CONTRACTOR CASING OVI pO DOMESTICIP NATE Id GRAVEL PACK/NZE TYPE OF CASINOISTEEL/PVC PVC DIA.OF WELL CASINO 8 II O� ❑ MBLICIMUNMIPAL ❑DRIVEN DEPTH OF GROUT SEAL 100 , SPECIFICATION B E N T O N I T E R C ❑ IRRIOATIONIAO ❑OTHER GROUT SEAL INSTALLED BY H E N N I N G S GROUT BRAND NAME WyE PEC ❑ MONITORING I L-n(1(/�� {%� GROUT SEAL MMD:,4A,�//y . ET Y. ❑N. CONCRE PEDESTAL SY DRILLER:❑Y. ON. S I APPROX.DEPTH I V V, I\ LOCKING CHESTER BOXISTOVE RPE S PROMBSO CONSMUCTIONIDRLLUNQ METHOD: MUD ROTARY X X AIR ROTARY AUGER CABLE L/ OTHER I HESERY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAMIN COUNTY OROINANCEB,STATE LAWS,AND RULES ANDC REGULATIONS OF THE BAN"AMIN COUNTY. HOME OWNER OR UCENGEO AGENT'S SIGNATURE CERTIFIES THE FOUOWINO: '1 CERTIFY T14AT IN THE PEWORMANCE OF THE WORK FOR WHIC'M' THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'{COMPENSATION LAWS OF CALIFORNIA.' CONTRACTORS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE MAPORMANCE OF THE WOR{FOR WHICH THIS PERMIT IS ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPPTISATON LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL K HOURS IN ADVANCE EOR ALL R QUIRE)INSFUTIONS AT MOST 46141423. COMPETE DRAWING AT LOWER AREA PROVIDED. @Ipn.6 x ` D B.y�41V(�u�' n 1'� D,,, 0 C T .8 , 19 9 6 ROT MN IDr.w Lo 1. NAME@ OF STREETS OR ROADS NEAM01'TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL @YBTEM OR PROPOSED 2. OITFLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. J. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WRHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PgRRTY OR ADJOINING PK)PERTY. •V I I i h A o r Q AJ : U D r' I I Ail' I I (i 096 DEPARTMENT USE ONLY / �• APPW.B.S A. uml 9, �� p� � DM. /��/� A,.�,�_ OrM In•.IIRw Br L- G DM.// I/j' p� MP Ir,.Psebn BY'Fy DM. Drlru•Ilen NRPAP1bn BY /T- DN• c•R1RI«B.: � �� l l SS - I b � ��' - 17 � u� _ ACCOUNTING ONLY: AID# FACS PE CODES FEE INFO AMOUNT REAVTTED C /CAM RECEIVED H DATE FEKIITISEIVIC[REQUEST NUMBER INVOICE 03a G 5-30 /0 is 96