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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SEir..JES PAYMENT ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388,446 N.SAN JOAQUIN ST.,STOCKTON,CA 96201.388 RECEIVED (209)468.3420 FEB 20 19x6 NDN-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN jC,',,1I,IIN(_c;uNTY IC4mpl4t4 in Triplicat4l PUBLIC NEA.!TI-I?,=:RVICES APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS[+4$IJ�.pgN IAtRCE"6*w JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3`AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC 04,HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR ARNO 'Z� C T r'IQr�C- STT�"�'�—CITY (S`TV Jr-0 Lel i ,t PARCEL SQE/APNJ OWNER'SNAME UZ_L -S�L-1� � /,., ADDRESS IL465 �.,. 1-\AL,01✓L SI✓�-40- PHONE 17-01 131-.7i,43f3 CONTRACTOR '5*N ( % i.vE'-Ay1-(of l'tiTiykI 'if - Wi�- ADDRESS IZ4'r0 G-✓Rp nI L.`S+- Q�- UC45►DfJG\ aPHONEI Z"T 5/ -Z": SUBCONTRACTOR JDLA•-\•�+� 1/Y AN r', ADDRESS Z' S - ✓L' TLA �• UCI G�IL7'b`PH.NEIZLI) qk.�5��1 aC n 1 1/.►1/1liJ tA� �� TYPE OF WEWPUMP: ❑NEW WELL ❑REPLACEMENT WELL ❑MONITORING WELL/ ❑OTHER Otf�J ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL I J ❑New❑Rq.ir H.P. DEPTH PUMP SET__FT. FIRST WATER LEVEL O (TYPE OF PUMP) ❑OUT-OF-SERVICE WELL ❑GEOPHYSICAL WELL I ❑ SOIL BORING B xDESTRLICTION: INTENDED USE TYPE OF WELL CONSTRLKTIDN SPECIFICATIONS q ❑INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING— D ❑DOMESTIC/PW VATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEUPVCV DIA.OF WELL CASING 1 2\. O 13PUBUCRMUNICIPAL 11 DRIVEN DEPTH OF GROUT SEAL ((,�,,ZIB, SPECIFICATION s0^ 14k3 Ry, ❑IRRIGATION/AG 1:1OTHER GROUT SEAL INSTALLED BY Lac.+jj-m L,Fo r� GROUT BRAND NAME_ .CVTV.NY I6LntdY1,E}1-r beMON-RING L GROUT SEAL PUMPED:f;!Ys ❑No CONCRETE PEDESTAL BY DWLLFR:❑Yr 0. 5 APPROX.DEPTH LOCKING CHESTER BOX/STOVE RPE S PROPOSED CONSTRUCTIONBXtlWNO METHOD:MUD ROTARY AIR ROTARY AUGER_CABLE OTHER I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.140ME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:-I 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: -1 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 REGUIRED INSPECTIONS AT(204)4483473.COMPLETE DRAWING AT LOWER AREA PROVIDED. Sian.dx QpiCAgM1., TRI._'pCb%,C��LS5upwy�'SCJr ) /�o.t.Z�lS�4(_ T PLAN IDrµto S-1.)Su -to 30' A#-,,IAA •1 V t 1 k,^ 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 PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3.DIMENSIONED OUTLINES AND LOCATION OF ALL EXMING AND PROPOSED S.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. i - a r7 I Bnr �' ENiPanCE . fT . yi u SDEwaL. a z 1 o� T-� T-1 rT1 \sAI —ea B#3 y/3-J Ix�l I =1 I I L J L J I oAA I Rfi^ 1 I I Pq` �sfe sem? R ... u,ic sTORu a+nw LEGEND: 1 4 Mwt MONITORING WELL s/I SOIL SAMPLE(6/9/86) SITE PLAN SHOWING PRODUCT LINES TRENCH SOIL SAMPLE LOCATIONS - 1 - — - VAPOR RECOVERY PIPE STOCKTON POLICE STATION -- _ STOCKTON, CALIFORNIA DEPARTMENT ONLr APPijw Ion Aeoyt.d ey 3 I Z-�,� Ara��/✓ 2 Grout Irapw:tlon By D..TO'YP-p IrrP.r 1_BY D..[ructlon In.p.etion By D.I.9� ✓Y�/� Commmm: '-- ACCOUNTING ONLY: AIDS FAC# PE CODE) FEE INFO AMOUNT REMITTED CHECKS/CASH RECEIVED BY DATE PERMIT/SERVICE..GUEST NUMBER INVOICE °�2 RD 312•yb o