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I _ APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAOUIN ST., STOCKTON, CA 95201.388 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED,THIS APPLICATION 15 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 5-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. �j �'!Sa(� 179-110-10 JOB ADDRESSIOR APN+r-• ��ry _ +`+� �,7...H�.99 .., _CITY�Q[k�T] PARCEL SEZEJJAPNi OWNLA'S NAME FR Manufacturing CorporationADDREss 2807 & 2829 S. Hwy.99 PHONE,(209)9482811 CONTRACTOR Gregg Drilling & Testing, Inc. ADDRESS Martinez, CA ..485165 PHONEs(510)313-5800 SUB CONTRACTOR ADDRESS L]CI PHONE TYPE OF WEUIPVMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL a ❑OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL r / D New 13Repalr H-P. DEPTH PUMP SET FT. FIRST WATER LEVEL p (TYPE OF PUMP) ❑ pI OUT-OF-SERVICE WELL 13GEOPHYSICAL WELL 0 IN SOIL BORING g ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SITE TYPE OF CASENG/STEELWC DIA OF WELL CASING D ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION A ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME f ❑ MONITORING GROUT SEAL PUMPED: ❑Yea ON. CONCRETE PEDESTAL SY DRILLfR:O Yr ❑Na S APPROX.DEPTH LOCKING CHESTER BOX/STOVE RPE s I� PROPOSED CONSTRUCTIONIORILUNG METHOD: MUD ROTARY AIR ROTARY AUGER`ZX_CABLE OTHER '�— be k I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES ANO- Q191 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,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'.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 ~a-1 CALIFORNIA.' 7 E APPLICA N T MUS C 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 1120'1{,�+5IRg3423. COMPLETE DRAWING AT RAWER AREA PROVIDED, r _ Slpned X._� fy L,.J� 11 ... THIa pX gO .CllZ t1-C.Y Ile C.L jq,.1 01 "ST Dne Ta .{ LPLOT PLAN IDra to Scale)Sulu'ta�_ 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED V ! 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 5. 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 ..._ . .........................................,..:............... . .. _. ... ... :..,.. ..... .. -- ... ............. - IL h DEPARTMENT USE ONLY k Applicatlon Acpwted By Groot Impaction By �wti6-'C/' t pate �p Impectlon by O.te 1 Dntmwticn lmppa tllom yBy Date Comments: ACCOUNTING ONLY; AIDS FAC# PE CODES FEE INFO AMOUNT REMITTED *X12401CASH RECEIVED BY DATE PEWITISUMCE REQUEST NUMaER �! INVOICE ,ie.. 7 3 55' 064, z