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APPLICATION FOR WELI.IPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES— "� V ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 96201.388 JUN 2 1 1995 (209) 468-3420 NDN-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH Umpt&t&in TTipikau► PERMiT/SERVICES APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANO/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 ADORESSIOR APN# 2701 N. Wilson Way cm Stockton, CA 95205 PARCEL SREIAPN# OWNER'S NAME U-HAUL Company of Fresno ADOREss749 N.Blackstone Ave, Fresno PpN,,(20 9) 487-1723 CONTRACTOR Spectrum Exploration, Inc. ADDRESS 2365 Wigwam Way LIC, 512268 PHONE,(209) 465-8712 SUBCONTRACTOR N/A ADDRESS Stockton, CA 95205 UC, PHONE TYPE OF WELLPIMP• 0 NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL fM--8 ❑ OTHER [ r ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL f ✓ ❑N..i❑P.palr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O !� TYPE OF PIMP ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL, Cl SOIL BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION& A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 811 DIA.OF CONDUCTOR CASING N/A D t 7 , ClDOMESTIC,PMVATE ❑GRAVEL PACKISIZE No. 2 TYPE OF CASINGmrmjPVC CT7VC DIA.OF WELL CASING 411 O ❑ P/BUC,'MUNICIPAL Cl DRIVEN Monterey DEPTH OF GROUT SEAL SR I SPECIFICATION l;-hptj11 1 P 40 R 4❑ IRRIGATION/AG ❑OTHER Sand GROUT SEAL INSTALL BY GROUT BRAVO NAME V(7T C-lII-A� E 21 MONITORING TT�� GROUT SEAL PUMPED: 5jy- No CONCRETE PEDESTAL BY ORILLFR:CRY— ON, S APMMX.DEPTH 95, DVS_ LOCKING CHESTER BOXISTOVE PPE E affi C Box S PROPOSED CON&TRUCTION/DISWNO METHOD: MUD ROTARY AIR ROTARY A AUGER CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK NILL 3E DONE IN ACCORDANCE WITH SAN 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 LL THIS PERMIT IS ISSUED,I SHANOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA,' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLL - I CERTIFY THAT 1N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFO IA. T APPLICANT MUST CALL 2A 110 ADVANCE FOR ALL REQLARED INSPPIECTT/IOONN4 AT(2001 40111-3423. COMPLETE DRAWING AT LOWER AREA PROVIDE � Slpnad X Tits. (�/L • D' S POT PLAN 1Draw 1.SuIN S`al. 1. NAMES OF STREETS OR ROADS N ST TO OR BOUNDING THE PROPERTY. A. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION, EXPANSKIN OF SEWAGE DISPOSAL SYSTEMS. 3, DIMENSIONED OUTUNES AND LOCATION OF AU 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. _......... .. ....... ....... .:........... ... __. ......_.._......._......_. ...................... r DEPARTMENT USE ONLY Applla♦tlon Appapted By � Ar.. Grout Ir,.p im BY Dae. PV p Irlap.cam BY D.C. f� Doovuctlm Inapacdm BY w .44MJ 7 9 ACCOuNTINO ONLY: AID# FAC, PE CODE& FEE INFO AMOUNT ROWTTED CNECK#/CASH RECEIVED&Y DATE PlOWITISERVICE REQUEST NLAM ER INVOICE �l 3 -Z/26:t�0 754 J