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J APPLICATION FOR WELLIPUMP PERMIT` JOAQUIN COUNTY PUBLIC HEALTH SERI( ENVIRONMENTAL HEALTH DIVISION ' ` P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201.388 � (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In Triplicate) { APPLICATION IS HERE BY MADE TO THE SAN JOAGUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK 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 ADDRESS/OR APN;r 10 O S e n rf CITY Stockton PARCEL SIZE/APN#I Francisco, OWNER'S NAME DiSalvo Trucking Co193765415 ! ADDRESS P . O Box San PHONE i CONTRACTOR-0j I PnI14it ADDRESS P . O . B o x 950 1 �^ LICN�PHONE N� SUB CONTRACTOR ILLI W G l_.(.J i N G ADDRESS O L C#519 NE x 1808 r V ��7r 2AZ- Cf/ - TYPE OF WELLIR MP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONrrORING WELL i A,.I OTHER SOl l TQbe With water-- ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL#r sample r ❑Naw❑Repair H.P. RYPE OF PUMP) DEPTH PUMP SET FT15-22/ FIRST WATER LEVEL „ p ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING B i ❑DESTRUCTION: �i ! INTENDED Use TYPE OF WELL CONSTRUCTION SPECIFICATIONS 11 A fNDUSTRIAL E3OPEN BOTTOM'! DIA.OF WELL EXCAVATION II DIA.OF CONDUCTOR CASING D ❑ DOMESTICIPRIVATE ❑GRAVEL PACKISIZE TYPE OF CASINGISTEELIPVC DIA.OF WELL CASING 'D ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL - SPECIFICATION R ❑ IRRIGATIONIAG ❑OTHER - GROUT SEAL INSTALLED BY r yeMl ra-hncP GROUT BRAND NAME Port I and cerrk-nt f ❑ MONITORING GROUT SEAL PUMPED: ❑Yes ❑No CONCRETE PEDESTAL BY DRILLER:❑Yes ❑No S' APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S. PROPOSED CONSTRUCTIONIMLUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CE T I AVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAID JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULAT S OF THE JOAQUIN COUNTY. HOME O ER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS IT IS ISSUE I NOT EMPLOY PERSO EJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES i TH LLOWING• CE THAT I gNCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF g LIFIRMIA." DVANCE FOR ALL REQUIRED INSPECTIONS AT 12091 4!93423. COMPLETE DRAWING AT LOWER AREA PROVIDED. s f xPres . -Oil Equipment Service .f{o�9 1 Till PLOT PLAN(Draw to Scale)Scale 1 "to 10, 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. r' 4. LOCATION OF HOUSE SEWAGE 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 6. 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. -. Pleasesee attached F'.igures 1 and 2.. w_ -:. . ... - . .. .. .. - - ...: -- _.. PAYMENT, :.....'..... . . Q(JifV �:f UN7J Y ...... �L€C HEALT E:RvicF ... P(J „. 1L f'�'GJb13s!C..1%. _. °. E��'Jlf�{�f�f�f�fv(f�1''F�CF ..,�y.�'��sL- — +�r.r-+.�- _ '_ T .`""` DEP�AR7MENT USE ONLY �_ � -. - - •-- _ �, licatlon Accepted By I Dete G Area Grote Inspection By Date Pump Inspection By Date bestructian Inspection By. Date 1 Comments: I i , ACCOUNTING ONLY: AIpIr FA.1 i PE CODES FEE INFO AMOUNT REMITTED CHECKN/CASH RECEIVED BY DATE PERM1TISERVICE REQUEST BER f 50 51 1 kl(At ` i