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APPLICATION FOR WELLIPUMP PERMIT <br />SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH 131VISION <br />P,O. BOX 388 304 EAST WEBER AVEC. STOCKTON, CA 95201388 <br />(209) 469.3420 <br />MON-REFURBAREE PERMIT EXPIRES 1 TEAR FROM DATE ISSUFU <br />M—PI.I• In Triolic:Td <br />APPLICATION M HER£ BY LIAM TO THE SAN JOAOUIN COUNTY FOR A DERMT TO CONSTRUCT ANO/OR INSTALL THE WORK MVCRIKO. T14M APPLICATION 18 MADE M Comt,ANCE wall SAN <br />JOAODUI COUNrY DE6TLOPF.IENT TrTLE. CHAPTER 9.1 115.3 AND THE STANOAKM OF BAN JOAOVW COUNTY PU&LtC HEALTI/ SERVICES. ET•IVRDNIJENTAL HEALTH OMISION. <br />JOB AOORESS/OR ADN/ 2908 Benjamin Holt Drive U G <br />CITY PARCEL SIZVAt1+i <br />OWNER -111 NAME_ ARCO Prndurhs Cnmoany AOORCCB <br />ft. -E S <br />CONTRACTOR SR(nR Tntprnat_innal ADORF68991.2 Business Park c,58399 <br />„f, <br />MM CONTRACTOR West Hazmat Dri.11in Corp. ADOf1CSB 3233 Fitgerald Rd C57 5549791 <br />AAAOW" RE}ATTED <br />_ �� PHONE v_ <br />REC>OVED EY <br />TYP-,OF WELt.RUMP. ❑ Ww WELL ❑ MPLAcr.ENT WELL -O.-ORING 'CJ 1A ti ❑ OTHF,q <br />"ELL A a��_�"I <br />T' <br />❑-.TALLATION ❑ WELL SYSTEI•I REPAIR ❑ CPOSS-CONNECT REPAIR D I ArpR EXTRACTION WELL 1 <br />sin <br />❑ ?4- O Reo.l• N.P. OFPTN dJMP SET )T. FIRST WATER LEVEL <br />J <br />RYP'E OF PVUPI <br />O <br />❑ OVT-OF. RFITVICE WELL ❑ OFor./YSICAL WELL t D wll BOiDNG <br />R <br />❑ DE6TRUCTIONt <br />INTEXDED VGE TYPE OF WELL CONFTRLICTION SPECIFICATIOMA <br />I ^ <br />❑ tNDUSTRIAL ❑ OPEN BOTTOM 01A- OF WET.L EXCAVATION / �• DTA, OF CONOVCTCR CASMO <br />^ <br />O 001A6 BT1C A3[TVA7E 13QRAVE{ PACK7PIZE 7YPF OF CAta.IG IfrTEElJPVC VC /I OTA. of WELL CASTNG <br />C <br />❑ 1VHUCMVNItCT1'Al ❑ DIt1VEN OEPTN OF OROUT DEAL rS SI cTFICATION <br />D <br />N <br />IRRIC:ATtON/AG ❑ OTHER GROUT $EAT. tNgTAILEV BY GROUT MAUD NAME <br />R <br />�❑ <br />qQ NONITORMQ QROVT SEA( I lu". ❑ .. <br />O� ❑ Y� CONCRETE PEDESTAL BY DRILLER: ❑ Yr ❑ No <br />S <br />APTNIOY. OEITH V,1�. LOCXW*G CHESTER ROXMTOVE PIPE <br />l <br />PROVOCED COMfTRUCTIORIDRILUMO ►AETNOO- MUD ROTARY AIR ROT AqY-- <br />AUCFIT Y CABLE_ ^_ OTHEq <br />S <br />I HEREBY CERTIFY T14AT 1 IIAVE P.EP^RED THIS APPLICATION AND THAT THE W'DW t^^LL Rc ODNE IN ACCOROANC�i %MTTNN CAN JOAOIRN COUNTY ORDINANCE% STATE I -A%". AND RULES <br />REGULATIONA T11E <br />ANO <br />OF SAN JOAOUIN COttNTY. HOME OwwFk OR LICEN"D AOENT"B WWATURE CERTWIEE' TRE FOLLOIMNO• -1 CERTIFY THAT IN TME PERTOTv.IANCF OR TtIF WOW FOR .„ ItgtCH <br />THIS PERufT M MUM I SHALL NOT EMPLOY PERCONB SUBJECT TO WOOK PAN'[ COMPTkItATION LAWS OF CALWOPMA - CONTRACTOR'S HNW40 OR BUD -CONTRACTING 61GUATUAC CERTIRE6 <br />- <br />TWE FOLLOWING; y� / <br />1 CERTIFY THAT IN THE PERFORMANCE OF TTIE V.404W "OR NMICH TRIC FERMTT If IRSUED. 1 SHATi MPLOY PERVOwR SUBJECT TO r+ORIOMAN•t CO.APEaI&ATTOM LAW OF / \. <br />N CO vBat-..d <br />MUAT CALL 2A HOtM2 IM AOVANCB TOR ALL REOILITO W., ,wTIONR AT(200011a40ya�COM/'(�'TE ORAWtNR AT LOWER ARF^ <br />CALTFORNI A,0. <br />MNT <br />X <br />T.I. <br />ice' On• <br />a <br />I. NAMFR Of STREETS OR RQ REST TO OR SOUNDfNU THE Pr4)CV TY. t, LOCATION Of OUW iEWA" DISPCIAAL SYSTEM OR r1ROr06ED <br />Z. OUTLINE OC THE MOPERTY. QNMIO DMM-40TONS AND NORTH OTRECTION, E](PlW61OV OF eLvvAOE OTBPDHAL BYfITEMB. <br />J. D+F/ENStONEO OUTLINES AND LOCATIOW OF ALL EXISTMO AND PROMI;CO f. LOCATION OF Y4U8 WTT111I. RAOWV OF ONE NVNOITED FIFTY R. <br />STRLICTURES. NNKLUOINO COVETED AREAS SUCH AS PATIOt, DROVEWAYy, ANO WALKS. ON TNF PPOPIC TTY OR Ar!Lk I Par try <br />A -A-4- A -t -f BY� A, � <br />0,w 4.o..c. BT <br />O..TnN+bn t.narootlo.. <br />DEPARTMp1T Utf ONLY <br />Pumv kw-'(- By <br />D.T <br />. . . . . . . . . . <br />ACCOUNTING ONLY: AIDS FACE <br />PE COOED FEE INFO <br />AAAOW" RE}ATTED <br />CREC ICA 6N <br />REC>OVED EY <br />DATE TIA E 1 EDU[ BER INVOICE <br />sin <br />a o S ooal�Sl21 <br />Pub. Health Serv. - Enviro. 173 (3rK <br />