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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIk S <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388,446 N.SAN JOAQUIN ST.,STOCKTON,CA 96201.388 <br /> (209)468.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (C&mPMb in Trgrtat&) <br /> 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 <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESS1 V OR ARNO L l GQ syLi S'ei Rd�,L7y� CITY 1-14tk(♦A <br /> �T 1 (� n �/� `� --gyp �•�' y, {� j PARCEL SIZE/APN/ y C��+ 'y <br /> OWNER'S NAME ONCIA'i CC\ OLit' R-A SJk17T-.k NiS�V.TADDRESS 700 644 hip Vl� III <br /> —PHONE/G�1 GlY'3 G.Z.1 <br /> CONTRACTORSN'IT TN ENy.�InLN\evT}dI TtOv Lorin' ADDRESS 17y-,�(1)1D '1A` III UC/5t0�a"' PHONE 2`I 6.71_LzZI <br /> SUBCONTRACTOR S t CA.•t—M {j'ii\`t J� ADDRESS K12S E,:NY+'34.5-1'• i C;5t b PHONE/LVA4 AI S � � <br /> TYPE OF WELL/PI/MP. ❑NEW WELL ❑REPLACEMENT WELL MONITORING WELL/ ❑OTHER <br /> ❑INSTALLATION ❑WELL SYSTEM REPAIR 11CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL 0 J <br /> ❑N—❑Rep.ir H.P. DEPTH PUMP SET Fr. FIRST WATER LEVEL O I <br /> TTYPE OF PUMP) <br /> ❑ <br /> �/ OUT-OFSEflVICE WELL ❑GEOPHYSICAL WELL/ 13 SOIL BORING B <br /> .SI DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS { A <br /> ❑INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION O vV DIA.OF CONDUCTOR CASING •�"+� D <br /> ❑DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC -- �V L DIA.OF WELL CASING Z D <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL ���'' ' SPECIFICATION SLIM 4I1_ _ // q <br /> ❑IRRIGATION/AG El OTHER GROUT SEAL INSTALLED BY 'f�� GROUT BRAND NAME <br /> MONITORIJLNG GROUT SEAL PUMPED: Y. ❑No CONCRETE PEDESTAL BY DRILLFR:❑Yr &No S <br /> APPROX.DEPTH 30 I LOCKING CHESTER BOX/STOVE PIPE S <br /> PROPOSED CONSTRUCTION/DRILLING METHOD:MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOWC WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> 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 <br /> THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN-1 COMPEN&A770M LAWS OF CALIFORNIA.-CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'&COMPENSATIOM LAWS OF <br /> CALIFORNIA.'THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL RECUIRED INSPECTION&AT(20911 746653123.COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Sial!X� 0.0 MAn/_/ Yhd1A/L Till._Pf-0 ..f`�/�(rt{'taCGILI� De. .5 Z55 ro <br /> PLOT PLAN(13—to ScJa1 Sul. i •to aLi' <br /> 1.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2.OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERgAREAS SUCH AS PATIOS,DRIVEWAYS,AIN1D WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> N MAINTENANCE _ ----- <br /> SHOP <br /> SHEDSTORAGE <br /> r <br /> STORAGE iOu i o6w OFF <br /> ICES <br /> M SHED iLL . <br /> �w HN _C�EVIER .. <br /> w �> <br /> N SEWER 100' - &NST <br /> um � <br /> zw O <br /> 3m <br /> MAT <br /> CENTER - <br /> o i <br /> 3 <br /> SCHOOL SW-319 <br /> PARKING t;N I MW-I <br /> nl SB-2 /EXCAVATION <br /> LB-3SB-3 <br /> ADGE OF <br /> +; I MOBILE <br /> 2-1/Y GAS I ILII HOME <br /> p 3-NATER /MW-2 <br /> Q <br /> p <br /> 'fes\ DISTRICT <br /> E I ( a OFFICES <br /> 0_ 1� <br /> VEHICLE GAS <br /> PARKING it <br /> ((JI O JE-S <br /> '...... . LOUISE AVENUE ... <br /> GENERALIZED SITE PLAN <br /> MANTECA UNIFIED SCHOOL DISTRICT :- - <br /> -- .LEsieD 2901 EAST LOUISE _...... <br /> ­30 =GROUNDWATER MONITORING WELL LATHROP, CALIFORNIA <br /> DEPARTMENT USE ONLY / <br /> Application AmgtW By Date ✓3D 1 {O Arr <br /> Gr Irrpectlan 8 u Data Pump I vpmtlon By Dat. <br /> Da.truction Imp—tion By D.te <br /> Damman.:_�rnsSure QY`Dy� <br /> ACCOUNTING ONLY: AID/ FAC/ <br /> PE CODES FEE INFO DONT REMITTED CHECK//CASH I FLOCEIVED BY DATE PEAMITMORVICE RECUEST NUMSHI INVOICE <br /> 2vo01 D' 0 <br />