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-' APPLICATION FOR WELLIPUMP PERMIT �- -�-- --- <br />SAN JOADUIN COUNTY PUBLIC HEALTH SERV <br />ENVIRONMENTAL HEALTH DIVISION <br />4 P 0 BOX 388, 446 N. SAN JOADUIN ST., STOCKTON, CA 95201-388 <br />(209) 458.3420 ' <br />NON-REFUNDABLE PERMIT EXPIRES I YEAR FROMIDATE ISSUED <br />lComploti in Triplicate) <br />Application is here by made to the San Joaquin County for a permit to construct arid/or install the work described. This application is <br />made in compliance with San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br />Services, Environmental Health Division. I} <br />Job Address/or APN# 177-040-17 city Stockton Parcel Siie/APN# 4.4—acres <br />I <br />Owner's Name Stockton Airport Industr4kiress 1010 2nd Ave.. San Diego 92101 Phone 061912I5 -105f1 <br />Contractor Frontier Drilling Address 1730 Hammond, Tti lock Lic#671904 ^� Phone #8M/?f11 —(191 1 <br />Sub Contractor N / A Address Lic# Phone # <br />TYPE OF WELL/PUMP: {) NEW WELL [I REPLACEMENT WELL <br />[] DESTRUCTION [] OUT -OF -SERVICE WELL <br />D INSTALLATION [I WELL SYSTEM REPAIR <br />[I New [I Repair H.P. <br />(TYPE OF PUMP) <br />11 <br />0 MONITORING WELL # <br />I] GEOPHYSICAL] WELL #' <br />0 CROSS -CONNECT REPAIR <br />1 <br />DEPTH PUMP SETT FT. <br />M OTHER Hydropunch <br />0 SOIL BORING <br />VAPOR EXTRACTION WELL # <br />FIRST WATER LEVEL <br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br />[] INDUSTRIAL [I OPEN BOTTOM DIA. OF WELL EXCAVATION I DIA. OF CONDUCTOR CASING <br />- <br />(3 DOMESTIC/PRIVATE 0 GRAVEL PACK/SIZE TYPE OF LASING/STEEL/PVC DIA. OF WELL CASING <br />[I PUBLIC/MUNICIPAL [I DRIVEN DEPTH OF GROUT SEAL full depth SPECIFICATION <br />[I IRRIGATION/AGI OTHER �y�io�p�r/Ic�i GROUT SEAL INSTALLED BY Fonder GROUT BRAND NAME <br />Kl MONITORING GROUT SEAL PUMPED: [] Yes II No CONCRETE PEDESTAL BY DRILLER: 0 Yes [] No <br />APPROX. DEPTH r In r I LOCKING CHESTER BOX/STOVE PIPE11 <br />PROPOSED CONSTRUCTIONfORILLING METHOD: MUD ROTARY AIR ROTARY_ AUGER_ CABLE OTHER <br />I hereby certify that I have prepared this application and that the work will be done in accordance with Sen Joaquin County Ordinances, <br />State Laws, and Rules and Regulations of the San Joaquin County. Home owner or licensed agent's signature certifies the. following: "I <br />certify that in the performance of the work for which this permit is issued, 1 shalt not employ persons subject to WORKMAN'S C014PENSATION <br />Laws of California." Contractor's hiring or sub -contracting signature certifiesi.the following: " 1 certify that in the performance <br />of the work for which this permit is issued, I shall employ persons subject to WORKMAN'S COMPENSATION Laws of California." THE APPLICANT <br />MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT (201) 488.3423. Complete,' drawing at lower area provided. <br />Signed <br />or FronticMtle Consulting Engineer Date <br />PLOT PLAN (Draw to Scale) Scale to <br />1. flames of streets or roads nearest to or bounding the property. 4. Location of house sewage disposal system or <br />2. Outline of the property, giving dimensions and North direction. proposed expansion of sewage disposal systems. <br />3. Dimensioned outlines and location of all existing and proposed j 5. Location of wells within radius of 150 ft. on <br />structures, including covered areas such as patios, driveways, the property or adjoining property. <br />and walks. SEE PROPOSAL LETTER OF XXXXXX 10/19/95 <br />Appiicatfon Accepted By, <br />Grout Inspection By, <br />Destruction Inspection By. <br />ACCOUNTING ONLY: I AID# <br />PE CODES I FEE INFO I AMOUNT REMITTED <br />�DEPARTMENT USE ONLY <br />II <br />_ Date Pump Inspection By. <br />P <br />Date Comments <br />FAC# I <br />H I RECEIVED BY I DATE PERMITP <br />Date <br />:E REQUEST NUMBER INVOICE <br />7&D <br />