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t ,,,APPLICATION FOR WELLIPUMP PERM SA AOUIN COUNTY PUBLIC HEALTH S*CES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED leemptEle In 7111plktltl APPLICATION IS HERE BY MADE TO THE BAN JOAQUIN COUNTY FOA A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WRIT SAN JOAQUIN COUNTY DEVELOPMENT TRUE,CHAPTER 9.1115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOBADDRESSIDRAPNI 540 West Scotts Avenue CITU St-ockton PARCEL BIZEIAPNIJ 47-0740.0-49 OWNER'S NAME ACME-Stockton Galvanizing ADDRESS 3564 Gresham Court 94556 PHONES (415)772-9662 CONTRACTOR WILLIAM DUBOVSKY ENVIRONMENTAL ADDREG63931 T.unPTRan Rd, 95(g(317 660066 PNONEI(91F�1-43R SUBCONTRACTOR Bayland Drilling ADDREBB811 Hamilton 94063 „DIC57-374154,,, 415 3�2/2�-y2(, R V TYPE OF MUJPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL/ ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL F ✓ ❑N.❑P. .I' N.O. DEPTH R/MP SET-FT. FIRST WATER LEVEL O RYPE OF PUMPI ❑ OUT OFSERVICE WELL ❑ GEOPHYSICAL WELL/ ELaa IC 1ffO1L BORING ORP B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM CIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D ❑ DOMESTIC"IVATE 11 GRAVEL PACK/SIZE TYPE OF CASINOISTEEUPVC OIA.OF WELL CASING O ❑ PVSUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PIMPED: ❑Ys ❑Ne CONCRETE PEDESTAL BY DRILLER:❑Ys [IN. 5 APPROX.DEPTH LOCKING CHESTER BOX/STOVE PPE 5 PROPOSED CONI TRUCTION/DPIILUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WUIK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE HAWS,AND RULES AND REGULATIONS OF THE BAN JOAQUIN COUNTY. ME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED HALL NOT EM PIPING SUBJECT TO WORKMAN'{COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR 8118-CONTRACTING SIGNATURE CERTIFIES TIM POLLOWIN ERTIFY T E PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'{COMPENSATION LAWS OF CALIFORNIA.• AP M CALL 24 HOOKS IN ADVANCE FOR ALL REOUIRED INSPECTIONS AT 120{14011 f 211. COMPLETE DRAWING AT LOWER AREA PROVIDED. BmR.a X/ T111e Consultant/Contractor D.,. 8/22/97 PLOT PLAN IM.1.IMW.l Be.l. •to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PtOP'OGEO 2, OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DIBPDSAL SYSTEMS. 2. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY R. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. e 'Q-4c,,l ✓�-.I^� DEPARTMENT USE ONLY A1,11..11.G Aveep,ed By Olevl Impeellon BY Dae Pump IR.pee11eI1 By ONe Dnbwll.n In�n.e,le^BY D.,a Cemmo-N.: ACCOUNTING ONLY: AIOF FACS PE COOEt FEE INFO AMOUNT REMITTED CHECKIICASH RECBVED BY DATE PERMITISFRVICE MOUNT NUMBER INVOICE 25 6 Pub,Health Sew.-Enviro.173(1197)