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APPLICATION FOK WELLIPUMP PERMIT WAN JOAQUIN COUNTY PUBLIC HEALTH SERVO ENVIRONMENTAL HEALTH DIVISION RO, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 9520 (2091468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICamplatB In Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPUANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBUC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOBADDRES6roRAPNJ 280792829 S. HWY 99 CLTY Stockton, CA PARCEL SIZEUFNs OWNER'S NAME FMC Corporation ADDREBBPhiladelohia, PA PHONE 215-2931-6.r, CONTRACTOR Hydro-Search, Inc. ADDRESS Sacramento, CA LIC# 655153,,,,E, gl SUR COMPACTOR Gregg Drilling r� ADDRESS Martinez, CA ucJ 485165 PHONE) Tt�„rQ-3].3- TYPE OF WELL/PUMP: 11NEW WELL ❑ REPLACEMENT WELL Q MONITORING WELL, 1-3 ❑ OTHER d2j � ❑ INSTALLATION Cl WELL SYSTEM REPAIR Cl CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J ❑N.Cl RrPB H.P. DEPTH PLUMP SET_FT. FIRST WATER LEVEL 0 (TYPE OF PUMP ,T OUT-0FBERVK:E WELL Cl GEOPHYSICAL WELL I Cl SOIL BORING B [R LJ y1DESTRUCTION: _3 monitor wells and 1 out-of-service well by pressure grouting S arr rhar9 vorknl an god wP_ ngs or cons Luc 10[1 1nn�OLIDa 10 INTENDED USE TYPE OF WELL CONSTRUCTION SPECIRCATIONS A Cl INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING O Cl DOMESTIC/PRIVATE ❑GRAVEL PACK/e2E TYPE OF CASINGRSTEELP'VC DIA.Of WELL CASINO nnD� ❑ PURUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION Y+R- IRRIGA By GROUT BRAND NAME ❑ MONITORING ❑OTHER GROUT SEAL IRIMPED D❑Yr ❑No CONCRETE PEDESTAL BY DRILLER:❑Vr CIN. Cl MONITORING _ APPROX.DEPTH LOCKING CHESTER BOX/STOVE RPE S PROPOSED CONSTRUCTION/ LUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER _ n 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 AHr 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 W64 THIS PERMIT IB ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'{COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUS{ONTRACTINO SIGNATURE CERVI THE FOLLOWING: ' I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED.I SHALL EMPLOY PERSONS SUBLIECT TO WORKCOMM MAN'S COMNMTION !AWB CAUFORNIA.' THE APPLICANT MUST CALL L24 HOURS IN ADVANCE MR ALL REGURIED INSPECTIONS AT 120014410�- . COMPLETE GRAWING AT LOWER AREA PROVIDED. SlgMX ��/i/fli�i>>�.—_ TM. PLOT PLAN IM.to ea l 6uIP 'to 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 PPOPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE USPOSAL SYSTEMS. J. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED B. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WALKS. ON THE W10PERTY OR ADJOINING PROPERTY. n DEPARTMENT USE ONLY APPI1e.tien Aooeptetl 8Y D,ta � q � Arr l G'.Vt Imoeetlen BY \ Orta P p IMINNaIPn BY 1r /I Dns Drvwtlen Inprtlen BY ,d Orta 1 I G ACCOUNTING ONLY: ND, FAC# PE CODES FEE INFO AMOUNT REMITTED CHE CASH RECISWO BY DATE P TISERVICE REQUEST NUMBER INVOICE 20,06 /409