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APPLICATION FOR WELLIPUMP PERMIT *SAN JOAOUIN COUNTY PUBLIC HEALTH SERO ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 9M1-348--- (209) 5201388(209) 488.3420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUED PI 2: 23 (Complete In Triplicate) APPLICATION IB 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 WRIT SAN JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 91115.3 AND THE STANDARDS OF SAN JOAQUIN COUUNNNTTYY PUBLIC HEALTH HHEAALLTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APNI� /'/ - /V"IV Y D� CITY ✓i wr"/l/A 1 JPARCEL SIZE/APNI Shell ll ®// ff ADDRESS FP f3a C 13 "j PHONE♦ OWNER'S NAME --- ADORES ADOREBun Y UCl {/(` PHONE( CONTRACTOR&01V G&h 7S (v UCI &,720/-7 PHONE(B -y6'5'9�1s�t 8 BUBCONTRACTORV7*)jADDRESS& /OWov TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL! ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROS&CONNECT REPAIR ❑ VAPOR EXTRACTION WELL l J ❑N.❑Roed, N.P. DEPTH PUMP SET_FT. FIRST WATER LEVEL 0 ITYPE OF PUMRI /C�[a h ��❑ DIET-OFBERVICE WELL ❑ GEOPHYSICAL WELL! SOIL BORING - S DESTRUCTION: / �E��FCs %�W/ INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION `/"'- /� DIA.OF CONDUCTOR CASING" D T ❑ DOMESTICMIUVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEELIPVC Ali DIA.OF WELL CASING iL D ❑ P/BUC MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BV GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Yr [IN. CONCRETE PEDESTAL BV DRILLER:❑Vw ❑Ne s APPROX.DEPTH LOCKING CHESTER BOX/STOVE PPE S PROPOSED CONMUCTIONMRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABIF OTHER 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN 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 WOR(FOR WHICH THIS PERMIT IB 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 WOW FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' HE PLI NT MUST CAO-04�I HOURS lIN(,ADVANCE F/OIL ALL REGUWED IINNIFRT10NS AT 1= j 4410-3433. COMPLETE DRAWING AT LOWER AREA PROVIDED. §IoM X`/ AtfV /'F/��1//�tL/ Y�/ l TRI. �"T®z / (f/� D.I. M M/rCF'/a LOT PUN ID,.IP BaNel Sule tP 1. NAMES OF STREETS OR ROADS NEAREST TO OR B NOINO 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,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. ®MW IF MWy EARTHEN BERM N I_ ig® MWS 18 O I Ma.] ® Y� LEGEND O e MW-10; 19 MW0 69 � M'W229 GROUNGWATER NONRCNWO WELL LOCATION MIG DESIGNATION 1> O 1, ®MAW MW IA DUALCWPLE=OMGPWNONATERSOILVAMRE%1RACTIGM NW.A® WELL LOCATION AND RESIGNATION I 6 BE OW 10 GRWNONATER MONITORING WELL LOCATION AND DESIGNATION wfl O IL. PROPOSED FOR DESTRUCTION 1 UNITMW] TMINB� 0.„ 12 N i1 MW.1] MW-12 BIGY TANK I-- OFFICE MNW 1] �OIWATER ®MW.IB F---j SEPARATOR GARAGE LWDING . RACH Mry Pa '',21 .. MW.1® Ly MW.r Owa LI IN ®LAW RE SHELL OIL PRODUCTS COMPANY DISTRIBUTION PL ART MODULE: 9515 Navy 0 ve PAC61C ]GALE 2 \\\ ENVIRONMENTAL RQ� Socpon.m o,na PROJECT GROUP.INC. 1 0 FEEL BITE MAP 905 13510