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P CATION FOR WELLIPUMP PERMIT SAN � IN COUNTY PUBLIC HEALTH SERVICES E GONMENTAL HEALTH DIVISION P 0 BOX 388,446 N.SAN JOAOUfN ST,STOCKTON,CA 96201.386 (209)408.3420 NON-REFUNDABLE PERMIT EXPIRES f YEAR FROM DATE ISSUED (Complete in Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOA A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN TITT JOAQUIN COUNTY DEVELOPMENT LE.CHAPTER 9-1115,3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH Dt"PON. JOB ADDRESSIOR API, 1603 South B Street CITY Stockton PARCEL SIZElAPNA OWNEF'SNAMF CA Department of Transportation ADDF¢GS 1976 Charter Way PHONE IF 209-948-7873 CONTRACTOR Geocon Environmental Consultants ADDRESS 3235 Sunrise Blvd P,IDHF,916-852-9118 Inc.SUBCONTRACTOR 4esteXl ADDRESePO Box 1664 W. Sac �"S3/�� 1.NE,916-373-1118 TYPE OF WELLNUMP; (2 NEW WELL ❑REPLACEMENT WELL ❑MONITORING WELL I ❑OTHER ❑INSTA LATION WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL, J 13 New❑Pe lr N.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O HYPE OF PUMPI ^• ❑OUT-Of-SERVICE WELL ❑GTOPHYSICAL WELL, ❑ SOIL BGRING g ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION LPMACATFONeA 1ry3 INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 10" CIA.OF CONDUCTOR CASING_ ❑ I..1 DOMESTIClPFUVATE ❑GRAVEL PACKIStZE#k3 Mon- TYPE OF CASINGISTEEUPVC PVC DIA.OF WELL CASING 4" ❑ ❑PUBVCJMUNICIPAL ❑DIVVEN tery sang DEPTH OF GROUT SEAL 151 SPECIFICATION g ❑IAMATIONIAG %OTHER GROUT SEAL INSTALLED E BY We$teX GROUT BRAND NAME E MONITORING GROUT SEAL PUMPED:aA Y. 13 N. CONCRETE PEDESTAL BY DFILLFR:Wvr Elm. 5 APPROX.DEPTH 100, LOCKING CHESTER BOXIGTOVE PERE S PROPOSED COMSTRUCTIONIONWN13 METHOD: MUD RDTARV AIR ROTAHI' AUGER X CABLE OTHER I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE 1N ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES ANO REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING;•I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FDR WHICH THIS PERMIT IS ISSUED,F$HALL NOT EMPLOY PERSONS SUBJECT TO WORIMRN'S COMPENSATION LAWS OF CALIFORNIA.'CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE MELD G: I C IFY THAT IN THE PERFORMANCE OF THE WOM FOR WHICH THIS PERMIT IS ISSUED,1 SHALA EMPLOY PERSONS SUSIECT To WORKMAN'S COMPVIeAT1ON LAWS OF CALIFORNIA.' AP A�INT/]NJTiH(T��CfJ�LL}I/N/Q/UR/SyI,'IN//h4OVANCE FOR ALL REGUIREO INy]yEOT10N(t/*T 120,/0(/�08.342233'�C�OMPLETE ED NG, kT LOWER AREA PROVIDE . SlOnea% /G Lam[/l IJP J�'% TE[Ie C!/�• / lC � / IO/�" L:!4 P.te PLOT PLAN L N'M—t.S -1 to I.NAMES OF StRE"S OR ROADS NEAREST TG OR SOUNDING THE PROPERTY. C 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 E.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. See attached site map. -7 � &,/?, // � !/a ��L � 'k DEPARTMENT LME ONLY nPPIk.IIe.�A�I.e Br r � .Lr �7 D.t. ?7•G�' /� Mw �J�J/ Creul Inp.nlen By D.1. 1 'Pvnv I.wpacRon By D.I. D..Ou.tbn Imwttbn BYO_ URIC T1('C(_C NO ll\J'Q 5 AOCOUNTINQ PNLY: AID, FAC, FE CODES FEE INTO AMOUNT NETAITTEO CHECKIIGADH RECBVMay DATE PE/IIMITISERNC ERFODUT NUMRRL INVOICE ��Ul !'6U V1�-a2` M01 '.FMC DU L