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QAPPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERV( ES 1- ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388,904 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 466.3420 fer� NOR-REFUNDABLE PERMIT EXPIRES f YEAR FROM GATE ISSUED (Complete In Trbllenel APPLICATION IB HERE BY MAGE TO THE SARI JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS'OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSMA rA�P�Neh 60 - l u�-; ��R F -_ crry 1/2q�y_I CA PARCEL BRE/M'NF OWNER'S NAME II13M tryl:' t�r�;-t,1C (,G iQ:i1 SIR I:cT `•"l ADDRE68 ,l tom('-,'-�.-4C-2�')E.�— PHONE( CONTRACTOR V2LC. IT �:rr Cr F'+dZR ;..C"` 1 f' 'Tt'q(rh S• ( ADDRE68 1-v. CA NcljcUC:16SISL:I PHONE, J'•--J�.SF! ,\ L� �Tr Z73sSUBCONTRACTOR I � C ADDRESS y wFRS 4S LC, t 4 PHONE,Nt.S—WD L 4ff FT I' TYPE OF WELL/PUMP: 9NEW WELL WELL. D ❑ REPLACEMENT WE MONITORING WELL♦ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR -❑ VAPOR EXTRACTION WELL, JJJJ� 11N.13 Nagel, H.P. DEPTH PUMP SET_FT. FIRST WATER LEVEL G (TYPE OF PUMPI € ❑ OUt-OF6ERVICE WELL ❑ GEOPHYSICAL WELL! SOIL BORING q ❑DESTRUCTION: I INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A 11 INDUSTRIAL 13 OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO 0 1 ❑ DOMESTICMOVATE 11 GRAVEL PACK/SIZE TYPE OF CASING/STEEVPVC DIA.OF WELL CASINO 0 ❑ PUBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION q j ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY Jjya LL 1 F;2 GREW BRAND NAME E JMONITORING GROUT SEAL PUMPED: ❑Ys F OX.DEPTH LOCKING CHESTER B❑/BIOVE PIPE CONCRETE PEDESTAL BV DRILLER:❑Vr [IN. PROPOSED COM6TRlICTION/geWNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER „pu I HEREBY 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:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS IGSUEO,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR BUR CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUF NIA.' APPAQA\N�\MUST 21/10 M6 IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT Ruq 4/6�6JE21. COMPLETE DRAWING AT LOWER AREA PROVIDED. Biome x �J n nne ��Z�a SCT 1 • IIS AjACF_� O.t. r7-I4—T) R7 7 s(, PLOT PLAN 40,—to OPE 6oJel 6uM�-to i, NAME OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE BEWAOE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. - EXPANSION OF RIEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OWUNE,6 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. N Parking Lot Storefronts 4 _ - loth Street MW-1 .. 1 MW-3 ED Former UST Location Farmer Pump Island M&M ® ® Existing Groundwater Monitoring Well, r �10 MW-I Installed Wright Dec., 1994 Investigation 8 / ..'. • _. Proposed Monitoring Well Location0 feet so P { - - • Proposed Boring Location I r I DEPARTMENTUSE ONLY Application Accepted BY Date Alz Ara 0,..Imp«tion By Dne Pump ImPectien By Det. 1{17 De•Lructien Imppyyy/«c�ti111,,,,JJJJ////ggggy/ Dna Comment•: �//i }7 ! ACCOUNTING ONLY: AID, FAC, PE CODER FEE INFO AMOUNT REMITTED CH (CASH RECEIVED BY DAT)E P IT/SM"CE REQUEST NUMBER INVOICE Lj.3 r Zl ��