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_ APPLICATION FOR WELIIPUMP PERI(�) ' C 73-7 SAN JOAQUIN COUNTY PUBLIC HEALTH SEn►..t5 OSS` S ENVIRONMENTAL HEALTH DIVISIONS �( P.O. BOX 388, SOS EAST WEBER AVENUE, STOCKTON. CA VM1388 12091 469.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR,FROM DATE ISSUED lComplate I9 TTlpiio9t91 APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR'INSTALL THE WORK DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE WITH I JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1116.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH Di%ASION, JOB ADDRESS/09 APN# 10480 N Highway 99 (Kid I N Tower) CITY Stockton PARCEL SIZE/APN# 086-070-34 OWNER'8 NAME Si I verado Broadcasting ADDRESS 6820 Pacific Avenue #200 Stockton, SONE# 209 476 1231 CONTRACTOR Earthtec, Ltd ADDRESS 1830 Vernon Street #7 Raafville,95 PHONE*6 786 526: -. SUB CONTRACTOR ADDRESS LIC/ 4085PHONE# TYPE pF WELLMUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL• © OTHER GEOTECHN I CAL SOIL BOR CNG ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# RYPE OF PUMPI 11New 13Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL - ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# tc 71 SOIL BORING ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS _ ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA,OF CONDUC RCASINGµ - ❑ DOMESTICIPFUVATE ❑GRAVEL PACKISIZE TYPE OF CASINGISTEEUPVC OIA.OF WE CASINO '} ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICA ION ` •� ❑ IRRIGATION/AG IaOTHER GROUT SEAL INSTALLED BY GROUT B ND NAME_&-,u a+e K 13MONITpRING - GROUT SEAL PUMPED: ❑Y. ❑No CONCRETE DESTAL BY DRILLER:❑Yea o APPROX,DEPTH,. _ ApprOX_501 LOCKING CHESTER BOXISTOVE PIPE PROPOSED CONSTRUCTIONIDRILLING METHOD: MUD ROTARY AIR ROTARY AUGER_ - x CABLE OTHER �- I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWSr AND RULES AI 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 WHIG THIS PERMIT 18 ISSUED,f SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SU"ONTRACTINO SIGNATURE CERTIFII THE FOLLOWING; 'I CERTIFY THAT IN THE PERFORMANCE.OVTHE WOW(FOR WHICH T1418 PERMIT IS ISSUED,I SHALL EMPLOY PER80NO SUBJECT TO WORKMAN's COMPENSATION LAWS CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED IN9P""""ON6 AT 2001460-3422. COMPLETE DRAWING AT LOWER AREA PROVIDED. ` t�L•^ Signed x � TIt1a Pr i nnc i tla 1 Consultant Dae 6/15/04 PLOT PLAN(Drew to Saale)Sole 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 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, SEE..ATTACHEA. MAP..::,. GEOTECHNICAL ONLY RCS EQUIPMENT IO'X 14' LEASE AREA : 'or am -.. . ....... � o�nc otxtvual N nvac TMa] 'aaa.m orw uw Tac t> 1 t O tc.a anew mu _ PAG,ti� D - VN. .__ Pmtsmiwp[ionIor NOTE: LOCATION OF ELECTRICAL g�1GR K� GS41 TELEPHONEAND SERVICE pu �0- 5UBIt:CTT TO ENGIRI G APN: 086-070-34 NO CHE ICAL TESTING /FROM PG&E BELL 134-0 I(11IN TD1tER I _ - TETRA TECH 111RELESS IM. TOIFER EXHIBIT B ' •)•i S.�ws[t C.,LL+xu[xl0.U+56J. 'a'��;tl++ DBA" - NOT TO SG1E ' DGPAp7MENT�UBE ONLY +.,xWo-'+`-'re" Appllcetlon Accepted By l/ (�' L `, / ' Pete '� ®V Area ( Gm-A Inap Tian B Date pump Inspection By Date Destruction Inopwtlon By pNa Cammenb: { ACCOUNTING ONLY: AID# FACIE PE CODES FEE INFO AMOUNT REMITTED CHEC!( ICASH RECEIVED BY D11TE PERMITISERVICE REQUEST NUMBER INVOICE .L as o�