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APPLICATION FOR WELL/PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON , CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUER (CBnI M TrOHMitol APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDOR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER B-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSMR APNR 6230 Pacific Avenue CITY Stockton PARCEL SIZE/APN# OWNER'SNAME Canepa ' s Car Wash ADDRESS 6230 Pacific Ave Stockton PHONE R 478-5515 CONTRACTOR Condor Earth Technologies , Inc . ADDRESS 188 Frank West Ste , PHONE 9 234-0518 RUB CONTRACTOR SDeCtrDm Exp] Orati on ADDRESS 2369 Wigwam 4tockT ( W# 1 263, PNONe # 465-8712 TYPE OF WEUJIPUMP: ❑ NEW WELL ❑ REPLACEMENT DEL. ❑ MONITORING WELL # ❑ OTHER ❑ INSTALLATION 13 MM SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL R ❑ Now ❑ ReFNt H.P. DEPTH PIMP SET FT. FIRST WATER LEVEL G ITYPE OF PIMP) Y'1 ❑ OUT-OFSERVICE WELL ❑ GEOPHYSICAL WELL El I SOIL BORING 2 g ❑ DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING ❑ DOMESTIC/PRIVATE ❑ GRAVEL PACKISIZE TYPE OF CASINO/STEELPVC DIA. OF WELL CASING O ❑ PUBUCIMUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL SPECIFICATION p ❑ IRRGATIONIAG ❑ OTHER SPOUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ OGROW SEALNUMPEO: ❑ Ya ❑ No CONCRETEPEDESTALSYDRILLEIR: ❑ Yaa [IN* S APPROX. DEPTH EPTH 7n I LOCKING CHESTER BOX/STOVE RPE S PROPOSED CONSTRUCTIONIDNILUNG METHOD: MUD ROTARY AIR ROTAPY AMER X CABLE OTHER I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE GONE M ACCORDANCE WITH BAN JOAQUIN COUNTY OFIDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF THE SAN JOADUIN COUNTY, NOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PEr60RMA K;E OF THE WORK FOR WHICH THIS PERMIT IB ISSUED, ISIHAM NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' COMPACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: ' 1 CERNFY THAT M THE PERFORMANCE OF THE WORK POR WHICH THIS PERMrt IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION HAWS OF CALIFORNIA - F APPLICANT MUST C 24 H OU14 IN VANCE MR ALL REQUIRED INSPFC'NON11 AT 12011141103/23, COMPLETE GROWING AT LOWER AREA PROVIDED. wq� X Tine Project Manager Det. PLOT PLAN IO.aw to Bowel Sow. to 1 . NAMES OF STREETS OR RADS AREST TO OR BOUNDING THE ROPEHTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM Ofl PROPOSED 2. OMUNE OF THE PROPERTY, O DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DRVSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED B. LOCATION OF WELLS WITMN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURER, INCLUDING COVERED AREAS SVC" AS PATIOG, DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY, Work Described - Work Plan - Soil and Groundwater Investigation , da1 .ted 1 /21 /089. by Condor . See attached Proposed Boring Locations site map . r \ DEPARTMENT USE ONLY Application Aecaptad By 11IL „ {� ,W\ Del. Mee Stout Impectlen By Date P P Inspection By Date 0004 LGM Inspection Br Date Com,nd„a: PEVA\ d Lft Irl A]! Kf& vp ay a1hK 6�_ L_- ACCOUNTING ONLY: AID# FAC# PE CODES FEEINFO AMOUNT REMITTED CHECKR/CASH RECEIVED BY DATE PERMITISEAVICE REQUEST NUMBER INVOICE n 15( d�eo Pub 4ealth Sew. - Enviro. 173 (1 /97)