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APPLICATION FOR WELLIPUMP PERMIT _ 3AN JOAQUIN COUNTY PUBLIC HEALTH SERV i ENVIRONMENTAL HEALTH DIVISION P,O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201 -388 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Compistb in Triplints) APPLICATION IS HERE By MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1115 .3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. o JOB ADDRESSOR APNN425 Larch Road DIT,. Tracy PARCEL SIZE/APNI 212 - 200 - 08 OWNER'S NAMEFrontier Trasportation ADORESB3577 Philadelphia Ave , ChU�IgE , 909 - 5908245 CONTRACTOR The Twining Laboratories Inc ADDRESS2527 Fresno St . , UDoC57 506 �„� SUBCONTRACTOR N / A ADDRESS Fresno , CA UC, PHONEF TYPE OF WELL/PIl 10 NEW WELL ❑ REPLACEMENT WELL ® MONITORING WELL F 3 ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL i ,Y ❑ New ❑ Remelt H.P. DEPTH PUMP SET FT. (TYPE OF PUMPI FIRST WATER LEVEL O cI ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL AFFFFFFF E3 SOIL BORING 9 ❑ DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑ OPEN BOTTOM L DIA. OF WELL EXCAVATION 1 / 4 tt DIA. OF CONDUCTOR CASING N / A D ❑ DOMESTIC/PRIVATE ® GRAVEL PACK/SIZE # 3 Sand TYPE OF CASING/STEEL/PVC--F`7 DIA. OF WELL CASING 2t� D ❑ PUBUC/MUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL 1095 ' SPECIFICATION S ch . 4 0 S c� ❑-tt IRRIGATION/AG ❑ OTHER GROUT SEAL INSTALLED BY t aT�fUr-- eni e GROUT BRAND NAME Po r t l and E Ej MONITORING GROUT SEAL PUMPED: 11 Yea 81 No CONCRETE PEDESTAL BY DRILLERZ YM ❑ Ne S APPROX. DEPTH 35 t LOCKING CHESTER BOX/STOVE RPE X S PROPOSED CONSTRUCTION/mOLUNG METHOD: MUD ROTARY AIR ROTARY AUGERX CABLE OTHER I HEREBY CERTIFY THAT 1 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 FOR WHICH THIS PERMIT IS ISSUED, 1 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 WOW FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.' THE APPUC T MUSTT CALL 24 NOME IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 1205) 48 23. COMPLETE DRAWING AT LOWER AREA PROVIDED. Slumeel x /iu ,P i/ Titled / Ir) rMG- UDate PAT PN (Drew to Stele) Scale I ' to 'iQ 1 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 PROPERFY, GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OMUNES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES, INCLUDING COVERED AREAS SUCH AT PATIOS, DRIVEWAYS, AND WAUCS. ON THE PROPERTY OR ADJOINING PROPERTY. . . . IF Ir M1 �intrD _ ' L/ .. . P �F(,7W [.lJ 7�C�ici'1 F�USTS�y, nc . OF I IF IF ILI IF P L s i PYDp�. AIFFIFFIFF I r 6cn� � nromSX , f i�crl'Y\el Diese � /J DEPARTMENT USE ONLY Application Accepted BY Date �^ r / ` Ates Grout Impaction BY Date Pump Inspection SY Date Destruction Inspection By Date Comm ACCOUNTING ONLY: AID/ FACS PE CODES FEE INFO AMOUNT RFTAITTEO CHFOISMASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE SLS ) VU S� l� � S/ Y / cS