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APPLICATION FOR WELLIPUMP PERMIT ' I -_ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION r P 0 BOX 388,446 N.SAN JOAQUIN ST.,STOCKTON,CA 96201.388 1209E 4693420 .NON-REFURDABLE PERMIT EXPIRES!YEAR FROM BATE ISSUED - rAmpIEtE In TrlplkEt•I R APPUCATION IS HERE BV MADE TO THE SAN JOAOVIN COUNry FOR A PERMIT TO CONGTRIJCT ANDlOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE iN COMPLIANCE WTIN BAN JOAQUIN COVNrY DEVELOPMENT TITLE.CHAPTER 9.111 5-3 AND THE STANDARDS OF SAN {JOAQUrN COUNTY PURUC HEALTH SERVICES•ENVIIIONME AL HEAL7II p1VIRION, j JOS ADDRE881OR APNE 0 `�, - lFr + �1 YLQ.+ rVvlluCITY rIYE�L.14 4+ c �e�ls ISL d7 .�`PARCEL SrZE1APNE OWNER'S NAME c t.jZ''err (I'QS •_ `,L'[L#pryt C0.,,, ADDREse W (,r(��W &�`A Oo ALL' E�6MIO.MroNFSIJPvJ BUD-SP r� CONTRACTOR ,JMiM1t N 1 LIMA n�CI VY ADDRESS�] GSM1 S1�1tJC/`�mza% PHDNEI Jy[!�IT{' •q+ 7 BUR CONTRACTOR % i!-40 LICE _ -� A4ONE T•'�IJ 74-Z8[S - S im Of WELLIVMP: ❑NEW WELL ❑REPLACEMENT WELL ❑MONITORINO W2LL E ❑OTHER ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSSCONNECT REPAIR ❑VAPOR EXTRACTION WELL■ ^ Q New❑fia.W, N.P. DEPTH PUMP SET FT. - FIRST WATf11,LEVEL p ITYIT:OF PUMP! ❑OUTOFSERVICE WELL ❑GEOPHYSICAL WELL R ' OESTRUCYIOR:_� -iAdA wt11S, .� l�1 L"IAt.�_Wekls { NTEND USE TY OF WILL CONSTRUCTION SPECIFICATIONS A .❑rNOUSTmAL ❑OPEN BOTTOM bIA.OF WELL EXCAVATION DIA-OF CONOUCTOR CASINO ❑DOLIESTICRIBVA-m ❑GRAVEL PACKI&ZF TYIS OF CASINGISTEEL/PVC- - DIA,OF WELL CAGING O ' ❑INJBLICIMUNICIPAI ❑DRIVEN ,DEPTH OF GIWVT BFAL SPECIFlCATION A 13 IRPoGATIONlAO ❑OTHER - GROUT PEAL INITIALLED BY GROUT BRAND NAME E ❑MOMTORDHG -7�- T+ GROUT SEAL PIMPED:111Ys Q Ne CONCRETE PEDESTAL BY OWLLFR❑YM ON. APPROX.DEPTH zs TI,f-+ ... LOCKING CHESTER MX/STOVE PPE / s PROPOSED CORSTRUCTIONWOLUNO METHOD:MUD VOTARY - AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION ANO THAT THE WORK WILL SF DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,ANO RULER ANp REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT-6 MONATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOIK POR WHI'C`o THIS PEP M F IB IS&MM I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSAT IN LAWS OF CAUFORNIA.•CONTRACTOR'S WANG OR EUBCONTRACTINLR SIONATURE CERTIFIES THE FOLLOVAM- •I CERTIFY THAT IN THE PERFOAMANCE OF THE VM"K FOR NMIC41 THIS PERMR IB ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WOII WAN'S COMPENEATION LAWS OF '\ CALIFORNIA.- TNF APPLICANT MUST CALL /1OUIIE IN ADVANCE FOR ALL REQUIRED 1NEPFCTIONS AT INLET 4EEa422.COMPLETE DRAWING AT LOWER AREA PROVIDES, SIS^°d X Iz- Tltl. D.te -�y .i PAT PLAY IDrMW ea S,:Y.I Sc.H.�_'la H 5-:� - 1.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDWO THE PROPERTY. 4. LGCATION OF"UBE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2.OUTLINE OF THE PROPERTY.OIVINO DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED E.LOCATION OF WELLS WITHIN RAWVS OF pNE HUNDRED FIFTY FT. O STRUCTURES,INCL NG COVERED AREAS SUCH AS PATIOS.DRIVEWAYS.AND WAI KR nv Tuc Iw,oc ,...,.,�..,..� , an no an,n _. „ L-� I� 4: Li / EARA E AN OFTICESiT SITE PLAN - V PGd,E TRACY SERVICE CENTER �'.• 502 EAST CRANTLINE ROA() TRACY, 'CALIFORNIA f ' - LE4CNR: PKIF.nro mn ;' -..._ "`•••111 w-, PGdEE SERVICE CENTER . u0uR0I.IG WELL I . ................... .. - TRACY, CALIFORNIA' L..,......:......4.-...i i APPROMIN.1[SC4LE MTH _ . ..,........... .a �e w EYL/ 1: 4-u-•i FIG RE F m.mra n.4KA - �N f:ss SHaxtr 04-I]]-.t .....---- ....: DEPARTMENT USE ONLY 7 ---.- - AW..If AAc..red BY Grace N.P-O n BY D•n pu'"W-- By i bwerueSen i,�pe.11nr,BY DH. CammsYr. ACCOUNTING ONLY: NW FAC/ PE CODES FEE INFO SUNT RDIOTTED CH /CAEIE RECDVLD BY DAYS PHRCTINERVICE REOUFET NUMSER INVOICE