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AppllootIon Aocopied By <br />AIDE ACCOUNTIND ONLY: FAC T <br />PE CODES FEE INFO AMOUNT REMITTED RECEIVED EY DATE f /sErmcE nrcnnEsT NUNIEFII INVOICE <br />' <br />APPLICATION FOR WELLIPIIMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />RO, BOX 3a8, 304 EAST WEBER AVENUE, STOCKTON, CA 95201-380 <br />(200) 400-3420 <br />NO11.11EFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />ICompkto In Triplient4I APPLICATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY WTI A PERMIT TO CONSTRUTAT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN comrtinNeF WITH SATI <br />JOAODIN COUNTY DEVELOPMENT TITLE, C/IAPTEn 9-1 115.3 AND THE ermonnos OF SAN JOAGUIN coDNTy PUBLIC HEALTH SERVICES, FILVSLONMENTAL I lEALTII DIVISION. <br />JOB ADDRESS/OR APN# 1766 Monte Diablo Avenue CITY Stockton PARCEL EIZE/APN# <br />25ft <br />T Yl'E OF WEU. CONSTRUCTION SPECIFICATIONS <br />0 OPEN BOTTOM <br />El GRAVEL PACK/SIZE. pea . TYPE OF CASINO/STEEIRVC PVC <br />0 DRIVEN DF.PTII OF GROUT SEAL. 15ft <br />El °Turn Gnour REAL It's TA! LED BY tremie <br />MA. OF WELL EXCAVAnoN 10-12 in ow or CONDUCTOR CASING n/a <br />DIA. OF WELL CASING 4" <br />SPECIFICATION bentonite <br />OWNER'S NAME <br />coNiFlACTOH Lush Geosciences <br />SUB CONTRACTOR V&W Drillers, PO Box 51 <br />Russell Chapin 1203 N. Carlton Ave., 9-464-4349 MK/NE <br />-3560 Business Pr., #120 916-737-9294 noonEB6 _,Sacto_...,_...9.5_8.2.1.Q__Lio#__Rs4421_ PHONE if <br />mmnFes Rio Vista,94571 mt710678707-374-2815 PHONE if <br />rysn <br />0 MONITORING WELL 0 0 OTHER -- <br />0 CROSS-CONNECT REPAIR Iti VAF'OR EXTRACTION WELL 0 V F.......5 <br />DEPTH PUMP SET FT. mgr. WATER LEVEL 2.0f t <br />0 0111-0E-SEnvIcE WELL 0 GEOPIP/SICAL WELL A' <br />TYPE OF WELL/PUMP; EX NEW WELL 0 111:PLACEMENT WELL <br />El INSTALLATION 0 Ma SYSTEM REPAIR <br />El New 0 Ftwalr <br />(TYPE OF PUMP) <br />BOIL Boma <br />tif 61, <br />DESTRUCTION: <br />INTENDED USE <br />INDUSTRIAL <br />DOMESTIC/PRIVATE. <br />PUBLIC/MUNICIPAL <br />El IRRIGATION/AG <br />DROVE BRAND NAME <br />12 MONITORING Gnour SEAL PUMPED: )13 Yon D No CONCRETE PEDESTAL BY DRILLERnYo• DNa <br />APINIOX. DEPTH LOCKING CHE.SfErt SOX/STOVE Firr <br />PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER X _ 01 HETI <br />I IIEREITY CERTIFY THAT I HAVE PREPARED TIIIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE Wirt) BAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RI/LEE AND 3 REGULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER 011 LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING; I CERTIFY THAT IN TI1E PERFORMANCE OF THE WORK FOR WHICH <br />THIS PERMIT 18 ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OIL BUS-CONTRACTING SIGNATURE CEITTIFIEB <br />THE FOLLOWING; " I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PETITIONS SUBJECT TO WORKMAN'S COMPENSATION I AWE O <br />CAI IORNIA.* THE APPLICANT MUST CAL). 54EFOLMSC III Am/,^ ICE TOD ALL REGUIRED L7:117,17-CTLELF-P. T !ITO) 4PS-1125. tP1FTE. DRAW'FIrL I T I 1,.."F.11 :41' rr.:FV:tr1). <br />SIT ,-.1 TIllo President <br />Dote 2-21-96 <br /> <br />LOT i't AFI {Draw to Gd.ho Capin <br />I. NAMES OF nrnms OR ROADS NEAREST TO OR flOUr MING I liE PROPERTY. <br />2. °MUNE OF THE PROPERTY, GIVING DIMENSIONS ANN NORTII DIFIFCTION. <br />3, DIMENSIONED OUTLINES AND LOCATION OF ALL Ey ,!:rING AND PTIOPOSED <br />STRUCTURES, INCLUDING covEne) AREAS SUCH AS PAtios, DRIVEWAYS, AND WAULE, <br />CZ) <br />LOCATION OF HOUSE. SEWAGE DISPOSAL SYSTEM on moil-mu) S> EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />LOC -VflOYI DI t.r, :WITHIN RADIUS or ONE NUEIONE1, r ii <br />ON "If IF f norrfrn• Oil ADJOINING PROPERTY. <br />Glout InspoctIon By iktikAr,... <br />Inspootic, BY_ <br />'rrtai _.407" Ett) IL*6-C <br />Dale 3/ ?/"-ei (,, rump Inevonlon fly <br />DEPARTMENT LISE ONLY <br />DAtc, 5i.“4/q6 Arno 4°' P <br />Oct, <br /> <br />^ <br /> <br />See Attached <br />