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APPLICATION FOR WELLIPUMP PERMIT %%,*4 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445 N. SAN JOAQUIN ST, STOCKTON,CA 96201-380 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Tripl-(ate) 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 SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER L9.1115.3yr,AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION JOB ADDRESWORJJA��PNN (�y V!/�',_,,Lr QS TC l &a "►A ��Vui �a CITY PARCEL SIZEIAPN/ (� �• OWNER'S NAME MCt Li`Ki l.. (SVS '. G I�.C`F•Y'a Z- i.G. ADDRESS J7� IArVtJ� 1A` KCi`�1/�.I�pQtYIQaTrHONE N�71V� ^��6iD� U� CONTRACTOR S L\i tv1-- ADDRESS I >•7C�1� DNS c0, PHONE+F SUS CONTtiACTQR i l/� ]Lt (y l r1Qi _ ADDRESS �•1 JI. na�} t SOL LICN PHONE TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL X ❑ OTHER ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ j ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMP( 1 C.� /-I ❑ OUT`-OF-SERVIC�E WELL 13GEOPHYSICAL WELL/ SOIL BARING 8 DESTRUCTION: Z J 1 l AOA v4k, � 2-iA06 W111 INTENDED USE Ty—PLOP—WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D ❑ DOMESTICIPRIVATE ❑GRAVEL PACK/SiZE TYPE OF CASINGISTEELJPVC DIA.OF WELL CASING D ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATtON/AG ❑OTHER GRDUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING -7 {7 GROUT SEAL PUMPED: ❑Yee 13 No CONCRETE PEDESTAL BY DRILLFR:❑Yr ❑NO S APPROX.DEPTH C.�� "Y�-e'+. LOCKING CHESTER B07U6TOVE PIPE (may $ PROPOSED CONSTRUCTION/DRLLINQ METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER wit 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:'1 CERTIFY THAT IN THE PERFORMANCE OF 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 SUBCONTRACTING 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 WORIOMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REGUIRED INSPECTIONS AT 12091 464-2423. COMPLETE DRAWING AT LOWER AREA PROVIDED. SlpnedX — Title�./L-.� /I'l/�4,(/ Date .1 f PLOT PLAN Mraw to Scala)Scale -to -5 1. NAMES OF STRELTS 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,INC COVERED.AREAS SUCH AS PATIOS.DRIVEWAYS.AND WAL"— __ --- --nau'iu pv+o'QT`�no ee••^ __ -. I N n . ...... a SUBSTATION - I a rn + Pw-s +Ow-a �w -m Fp RATERUmCER Ow-]+ GASOLINE GR JNDTAtIK Li - - -- - GARAGE AND OFFICES .. Dw-0+ SITE PLAN PG&E TRACY SERVICE CENTER 502 EAST GRANTLINE ROAD TRACY, CALIFORNIA LEGEND' PREPARED FOR _ +°M ' MONITORING WELL PG&E SERVICE CENTER - —..—�- FENCE TRACY, CALIFORNIA APPROXIMATE SCALE SiffH 40, DATE ISSUE/RE4151ON ar rD erwo er 40 O 49 FEET DATE: 4-13-95 FIGURE 1 OR4-472-AlAvar4 Numfk - AS SHOWN 9 SCALE. DEPARTMENT USE ONLY Application Accepted Arca Grour hrpwtU*A BY Date Pump impaction By Date