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APPLICATION FOR WELLIPUMP PERMIT fir^ SAN JOAQUIN COUNTY PUBLIC HEALTH SERV114 ENVIRONMENTAL HEALTH DIVISION r P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON. CA 952 I-M (209) 488-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In Triplicate) APPLICATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE WHH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSMR AAIPrr�YNL♦VG /��_ I[��-P �;RFs Clry 1pTpk .. . \(, PARCEL SIZE/ARID OWNER'S NAMEM A . ADDRESSl:Q T1CCC,CX:4(q,cr a,)II T •a l PHONE t F:.iS7C: I t'a1R1-�bet. � _ �. J CONTRACTOR%\kjZ Lr.UXr FF:r__.ii(�C/-t j�F- 4Z+L C � ADDRESS TCf�(:_� C1p� c1�S'7t.. ' LIC! LS(SL:I PHONE( 463- J•F! SUBCONTRACTOR �r'(• L. r MAIM? L \ t Z3 l'w c t F '�� \yZ- r.° 7 LSC- ADDRESS r.<ci(ic.aY A 9S LS ucl 5-1221.>E: PHDNE l N6S—H71Z- TYPE OF WELL/PUMP: PCNEW WELL ❑ REPLACEMENT WELLONITORING WELL! ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR �ROe6-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL! J ❑New❑IR.p.lr N.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O I (TYPE OF PUMP) ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL! SOIL BORING B ❑DESTRUCTION: I 1 INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPENBOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO G ❑ DOMESTICR'PVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEELN C DIA.OF WELL CASING O ❑ PUBUCB.LUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY I F 2 GROUT BRAND NAME E WIMONITORING GROUT SEAL PUMPED: ❑Y. [IN. CONCRETE PEDESTAL BY DRILLER:❑Vs ON. S I' APPROX.DEPTH LOCKING CHESTER BOXISTOVE RPE S 7LZE z 1 PILOroeFD CONST11lICT10N/DIeWNG METHOD: MVD ROTARY AIR ROTARY AUGER _CABLE OTHER l I HMBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY pERSON6 SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IB ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIF IA.' T/ APPLid\µ mUGT 24 Ute IN ADVANCE FOR ALL REQUIRED IN P`ECTIOLNS`12")4011) 2i. COMPLETE DRAWING AT LOWER AREA PROVIDED. Blamed% �a I ^ THD. I��S I� 1 ` I�n-lAGf;L1c D.t. PLOT PLAN IDr.w to Scale)Seel. P�'I. 1-S( 1. NAME OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE BEWAGE DISPOSAL SYSTEM OR PROPOSED 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 S. 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. Parking Lot Storefronts W --------------------------------------------------- I Oth __________________ IOth Street Former UST -- Location - i Former Pump Island _ - 1. Existing Groundwater Monitoring Well, Auto MW-2 _ Installed Wright Dec., 19941nvestigatiori ' Proposed Monitoring Well Location I `' • Proposed Boring Location U feet so - �.�.5. 1 DEPARTMENT USE ONLY �' •m/// ,{/J, Appllpatlon Accepted By Dere ` ✓ Are. Gmul Impaction BY Mile Pump ImPseftrt By Dna Destruction Inopw on BY Dne Comments: ACCOUNTING ONLY: AIDP FAC! PE CODES FEE INFO AMOUNT REMITTED CH /CASH RECEIVED BY DATE PEIeM1TISERWCE REQUEST NUMBER INVOICE � 3