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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201.388 (209) 488.3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Compbts iR Tripinto) 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 8.111 S.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOS ADDRESS/OR APN#_�2, L M (r� + L1,u, � c d T•� **I�ti te,� t- c-1 •try •w�c •C�,.y^1 n,� PARCEL SIZEIAPN# OWNER'S NAME "l L 5 (}ys t„ `Q ��„1 00w �,I;m )I,� LCGI r �r� —(�. Ff. � ADDRESS r `J V1.ICeQ L1'LQvHONE etc) W^,7 CONTRACTOR S►r+Wlli}+1 T.rL.r �4---(,[Sj� ,ADDREss.1 Cd4 `x-y'�i4 y1�CS,lSio�SiVLI 'soeQt S q`ZZZJ! �) "1 �-�� PHONE# SUB CONTRACTOR Y�� ,� n__51 i ADDRESS? BCI1 , 12:Q V 1 S+a LIc,T PHONE ��32q-Z81 5 TYPE OF WELLIPVMP- ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL fi'YPE OF PUMP) 0 ❑ OUT-oF•SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING � B XDESTRUCTION: Z 4 ' I Atli LAI k ' Z-1A jtA u6mkl INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ❑ INDUSTRIAL ❑OPEN BOTTOM IA.DIA.OF WELL EXCAVATION DOF CONDUCTOR CASING A ❑ DOMESTICIPWVATE ❑GRAVEL PACKlSIZE D TYPE OF CASINGISTEEL/PVC DIA.OF WELL CASING D ❑ PUUX/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION 13 R IRRIGATIONlAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME ❑ MONITORING E f� 1 GROUT SEAL PUMPED: ❑Yes 11 No CONCRETE PEDESTAL SY DPJLLFR:❑Yr ON. S APPROX.DEPTH "Tap-T LOCKING CHESTER BOXISTOVE PIPE ! _ S PROPOSED CONSTRUCTION/DRILUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER ptssslre, I 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 E THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA,' CONTRACTOR'S HIRING OR PERFORMANCESUR-CONTRACNG SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL LRREQUIRED INSPECTIONS AT(208)4683423. COMPLETE DRAWING AT LOWER AREA PROVIDED, Signed X n g AQ f` Title G /tom Date L PIAT PLAN IDraw to Scale)Scale"to 'i 5 t. 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,INCjW ING QVI:RED AREAS SUCH.AS PATIOS.DRIVEWAYS_AND WAI KS. _.�_ -1N..rMC-RRaC0rSV_nst an Inlu,u..en„ar a N N V - I SVRSTATION _.__.. }OW-4 } OW-6 }0W-5 a5 FORMER VNDERGRGLIND -_- ... Zw-2+ GASOLINE IWIK ....-.-... - u GARAGE AND OFFICES SITE PLAN PG&E TRACY SERVICE CENTER 502 EAST GRANTLINE ROAD TRACY, CALIFORNIA LI513END, PREPSRED FOR MONITORING WELL PG&E SERVICE CENTER —« — FENCE TRACY, CALIFORNIA - - • APPROXIMATE SCALE SMTH -lo. DATE Issue/RECISION er Kn erwow 40 0 4Q FEET DATE: 4-13-R5 FIGURE 1 ORAwrNG NurxDER SCALE: AS St10wN 94-432-A1 --- -- 1 DEPARTMENT USE ONLY `r} Application Accepted BY Grout Impaction 8y Date Pump Impaction By Date Destruction Impaction 0 Date Comments: ACCOUNTING ONLY: AID# FAC# PE CODFA FEE INFO AMOUNT REMITTED CHEC ICASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE S)7- W -Wye—) - noo all�-