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AN�PPLICATION FOR WELIJPUMP PER SARPDAQUIN COUNTY PUBLIC HEALTH SPACES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICDmpMte In TrIpROX1E1 APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION I6 MADE IN COMPLIANCE WRIT SAN JOAOUIN COUNTY DEVELOPMENT TALE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAGUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOBADDRESBroRAR+e 540 West Scotts Avenue Cm, Stockton PARCEL SIZEIAPNF147-040-48 OWNER'S NAME AC ADDRESS ACME—Stockton ton a vanizing RIONE Gresham Court 4556 5+�J7�—�5b62 CONTRACTOR WILLIAM DUBOVSKY ENVIORNMENTAL ADDRE663931 Luneman Road 9�,467 #660064DHEF(530) 621-43 SUBCONTRACTOR Bayland Drilling ADDRESS 811 Hamilton St. 9/{ 3 #3741UDNEP(650) 322-2 TYPE OF WELVPUMP. ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL E ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL A J 11N.0 FR * H.P. DEPTH PUMP BET_". FIRST WATER LEVEL O RYPE OF PIMPI ❑ OUTOF-SERVICE WELL ❑ GEORrv61CAL WELL A ❑ SOIL BORING B Ey,WAAA4x See attached work plan INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A 11 INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO O ❑ DOMESTICRNUVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA.Of WELL CASING D ❑ PUBLICMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Yr ❑Ne CONCRETE PEDESTAL BY DRILLEM O Yr ON. 5 APPROX.DEPTH LOCKING CHESTER BOX/STOVE RPE 5 PROPOSED CONSTRUCTIONIdtlLUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HE EBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WALL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAGUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH 7I419 PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN-8 COMPENSATION LAWS OF CALIFORNIA.- THE APPLICANT MUST CALL 24 HOUNS IN ADVANCE FOR ALL MOONING INSPECTIONS AT 12MI 408JS22. COMPLETE DRAWING AT LOWER AREA PROVIDED. Sly'wd X Tllb Consultant/Contractor D.I. 8/14/98 ROT PLAN(M..Y le S W.)Bcel. 'Ie 1. NAMES OF STREFFS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED 2. OUTLINE OF THE PROPERTY.GIVING DIMENSIONS AND NORTH DISECT1ON. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE NUNDGED FIFTY IT. STRUCTURES,INCLUDINO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. SEE.ATTACHEDWORK PLAN: pEPMTMENT USE ONLY r1 !/I� AvvIle.Uen APPeP1sA BY 'l/9T W LN[�V 1 '1 �I� Dete � L/ L6 Are. Grein lneOePRlen By D.I. TAKnO 1n.Pemlen By D.b n.nnsn..,L..reem Dv D.I. cemme,l.: "hl1'11�N�Ir' EIIMNt� !' IR1lRi G01RA�1V(' ti{' S/lh�il/n.�g1As �l/ $TJt/1/Tl/Y/.f� bitACCOUNTING ONLY: AID/ FACS LJI(� V PE CODES FEE INFO AMOUNT REMITTED HECK/ICASH RECEIVED BY DATE PERMITISENVICE REQUEST NUMBER INVOICE (06 - m-+ (0 7os Pub.Health SEN.-Enviro.173(1/97)