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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICEa ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON,CA 95201.388 (209) 468.3420 10111-REFUNDAW PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Mempiete In Triplintel 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 9.1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSIORAPN/ 17000 E. HWY-120 CITY RIPON PARCELSIZEIAPN! OWNER'S NAME THE WINE GROUP ADDRESS P.O. BOX 697, RIPON 95366 PHONE 594-4111 CONTRACTOR NOACK PUMP COMPANY ADDRESS 4500 E. FREMONT STLIC0 504513 PHONE/ T7 SUB CONTRACTOR ADDRESS LIC# - PHONE f TYPE OF WELLIPUMP ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL a ❑ OTHER ElI NE [3INST TION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR [3VAPOR EXTRACTION WELLx TUR8N J U I Nnew KRepa(r H.P. DEPTH RUMP SEI' FT. FIRST WATER LEVEL 50 O 1�C ff G T UMP FOR ❑ OUT-0F•SERVICE WELL ❑ GEOPHYSICAL WELL• ❑ SOIL BORING a b%jjZ@,I,INSTALLAT ION. INTENDED USE TYPE Of WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D PXDOMESTICIPRIVATE ❑GRAVEL PACKISRZE TYPE Of CASINGISTEEL/PVC DIA.OF WELL CASING D ❑PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION Ai ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL iNSTALLED BY GROUT BRAND NAME f ❑ MONITORING GROUT SEAL PUMPED: ❑Yr ❑No CONCRETE PEDESTAL BY DRILLER:13y- ❑No S APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTIONIMLIINO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 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:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED NOT EMPLOY PERSONS SUBJECT T WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: IFY 7 IN THE OF WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENiAT10N LAWS OF CAUFORNIA." THE n CANT C 24 1 jF C E FOR ALL REQ 4RED INSPECT ON$T F 1 SALES COMPLETE DRAWING AT LOWER DAREA PROVIDED, 1995 Slened X +' L RETAIL PLOT PLAN(Draw to Scale)Beale "to I. 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 OUTLINES 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. ....................... ..... ... ....'....- .. - ... ... ............. - .............. .... ...... ............ �i ...... ..... ...... ......... ....... ........ ..: . ...... .......... ............... .......................... ........... ...... ... ......... ............. .......... ............ ........... ....... . ................. ............. ......... ...... . ..... . ........... :.. .. . . .... :.. TY . �Q '� a ,. . 7:...... .. : ....,. VIF;� hE�il';t:F#cL 'H'fl��, t DEPARTMENT USE ONLY 1 L .Apdkathn Accepted By a Area Grant Iropectlat By Date Pump Irrpeation By 9 pate �e DaetnnNen lnepeadw By. Date Comments* ACCOUNTING ONLY: AH)# FACS - PE CODES FEE INFO AMOUNT REM/ ED NEC /CASH RECEIVED BY BATE POWITISE RVICE REQUEST NUMBER INVOICE ( 61.1--50 Z .QI o