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APPLICATION FOR WELLIPUMP PERMIT ] -SAN JOAQUIN COUNTY PUBLIC HEALTH SERVi"S ENVIRONMENTAL HEALTH DIVISION P.O. BOX SK 904 EAST WEBER AVENUE, STOCKTON, CA 95201388 12091468-3420 RON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED {Complete in TTIpIkEtol APPLICATION 18 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 TfrLE,CHAPTER 9-1116.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSIOR APN* 17950 Via Nicolo Drive CITY Tracy T PARCEL MZEIAPN* OWNER'S NAME Musco Olive Products Co. ADDRESS._17950 Via.Nicolo._Dr.-.,-_.Tracy .PHONE• - CONTRACTOR, Frontier .Drilling ADDRESS PO Box 4931.. Modestouc#68R979 PHONE/ � SUB CONTRACTOR ADDRESS LICK RHONE S TYPE OFWELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL* 13 OTHER ..... ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR © VAPOR EXTRACTION WELL I J ❑New❑Rep.lr H.P. DEPTH RUMP BET FT. FIRST WATER LEVEL - d RYPE OF PUMP) ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL I la SOIL BORING eote I'L TAV. " B �y 6 honticiues, 2_ max. MDEBTRucTroN: Borings backfilled with native material: groundwater not aate _ INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D ❑ DOMESTmmRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINOISTEELIPVC DIA.OF WELL CASING q` ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION IQ ❑ IRRIGATION/AFI ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E-1 ❑ MONITORING GROUT SEAL PUMPED: ❑Yee ❑No CONCRETE PEDESTAL SY DRILLER:❑Yes ❑No - S^ APPROX.DEPTH LOCKING CHESTER BOXISTOVE RPE S� I PROPOSED CONSTRUcralli aLum0 METHOD: MUD ROTARY AIR ROTARY AUGER XX CABLE OTHER a 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 FAR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERBONB SUBJECT TO WORKMAN-S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.* THE APPUCANT MUST CALL 24.HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT f20614SS-7421. COMPLETE DRAWING AT LOWER AREA PROVIDED. Blcnad x 0 Title Project GEolo ist Date 12111/96 PLAN IDtaw to Sahel 8oarsT•to 7_C;I0 ! 1. NAMES STREETS OR ROAD8 NEARE Tp OR BOUN THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED I. NL 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 2. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT- I STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. 0 .... :.. „-....... :. :.... iT {Sk'� F. . . .. . .. - ... 71 .. . .. . ...............,.......... 0. .... . . .. ..... ..... .... ...: ' 4, 1:1bA6 �>- t1�6i4� L r �'��t3�IC H��RL i H S�RVl . _ t :. EN .. . VIRQNME�€�'A ... —•r •r.-,�. r _. _ 4EP.AR7MEN7 USE:ONLYr APplrcatlon Accepted ByT�'�l _•_ Det. �2f l Ates 2/4 `J U Grout Impomron By Dote Pump Impectlon By Date!�t Desnuctlen Imgoatlen By 1 Data.._ Comments:. ACGOUNTINO ONLY: AID* FAC* 4 PE CODES FEE INFO AMOUNT REMITTED CHECINICASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMNOt INVOICE 4 43'7 2 150 1,5'0.