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APPLICATION FOR WELLIPUMP PERMIT � <br /> AN JOAQUIN COUNTY PUBLIC HEALTH SERVI`I <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON.ACA SMI 388 ��I_71 t <br /> (209) UB-3420 1°"{����t�'���`�.� <br /> NON-REFUNDABLE PERMIT EXPIRES-1 YEAR FROM DATE ISSUED <br /> (Complete in TTlprMtr) ° "' 1: � � 2. 25 <br /> APPLICATION IS HERE BY MADE TO THE CAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLUCATUON 18 MADE IN CONMRJANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT Trrm CHAPTER 8-111 S.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> jos AwREBBroaAPN, 3535 E. Cherokee Road cuy Stockton PARCEL IIWAPN# <br /> OwNER'BNAMECecchini , Cec„chihi , & Giovannoni ADDRESS 3000 E. 18th Street Antioch RiONE/ 51 - <br /> �. 0)„634 4400 <br /> co4rPAMOR Envi rorlmental Science & -Enai neeri ng,Inc oDwes 4090 Nelson Ave. LIc6 8022 PHONES(510)68'5- 05j <br /> MR CONTRACTOR_Soils Exploration Services (- E. ES) ADDREBe11383 P ri tes „C,-!i8 696 PHoNE , 161253(7848' <br /> TYPE OF tnL MP. ❑ NEW WELL ❑ REPLACEMENT WELL ® MOLBTORING WELL I — <br /> U5 F 55 ❑ OTHER _ <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ® VAPOR EXTRACTION WELL f_y P-I J i <br /> 13N.❑pw ,w, H.P. DEPTH PUMP SET FT. FIRST WATER LEVELLB <br /> RYPE OF PVEIPI <br /> OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORTNQ <br /> B <br /> ❑DESTRUCTION: ` I <br /> LN11E M USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ L mmmAL ❑OPEN aOTTOM k; DIA.OF WELL EXCAVATION--10-in cam_ DIA.OF CONDUCTOR CASINO D <br /> ❑ IIQMEST mmvATE ❑GRAVEL PACKISIZE 2� TYPE OF CAW M/STEELIPVC 2-jach PVC DIA.OF WELL CASINO —i n h D <br /> ❑ PUBLICOAUNICIPAL ❑ RI <br /> DVEN .DEPTH OF GROUT SEAL 28 feet SPECIFICATION I'la Chine 1 o t L ff11. 2 e <br /> I <br /> uvaGATIOWAG ❑OTHER GROUT SEAL INSTALLED BY SES GROUT BRAND NAME P o r t 1 a n d Cement F I <br /> 13 MONITORING GROUT SEAL PUMPED: ®Yea ❑Ne CONCRETE PEDESTAL BY DNUAFL❑Yr ❑Ne S <br /> APPROX.DEPTH 70 feet tOCKMO CHESTER SOXISTOVE RPE s /� <br /> PROPOSED CONSTRUCTIONlpNWNG METHOD: MUO ROTARY AIR ROTARY AUGER X CABLE OTHER e e <br /> _ (Hollow Stem) <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATION AND THAT THE WORK WILL BE DONE RV ACCORDANCE WITH CAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AMC <br /> REOULATION F THE SAN JOAGUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:`I CERTIFY THAT M THE PERFORMANCE OF THE WORK FOR WHICH <br /> PONTIS PERM ISI ED,1 W4 NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMP@LSATION LAWS OF CAE.IFOmw- CONTRACTOR'S HURING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FDLLO NO: I CERTIFY ATM THE PERFO ONCE OF THE WORK FOR WHICH THIS PERMIT M8 ISSUED,I SHALL EMPt.OY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFOIWIA CANT T 24 HO IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12”)404422. COMPETE DRAWING AT LOWER AREA PROOED. <br /> Sbtid X �:A <br /> TTtse Sen <br /> David Blunt <br /> PLOT PLAN m,M,to ser.,sesta—,to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNOM THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GMNG DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> n. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOIMNG PROPERTY. <br /> ......:..........................":......;.....:.......;..............._...:.......:......:.......;......:.....:......... ... <br /> ....:.......:.. ........;..,...........;.....":.......,......o.".....;......:......:....... . .. <br /> .. .:.S. .e. 4L tdC,hmr.rlr.....�........9;u.r. ...1...We]1...Des i.gn...... ...:.....:... .............. ......'......:. .. <br /> ........... :......i..................:............ � .. .. .. .. <br /> ,9�re.. �...W�.11....1..�.c.ati�n.;.. ..'.. ..>.. ..:.. ... . � � � ." ......... <br /> . <br /> DEPARTMENT USE ONLY <br /> Applloetien Aoeapted 8y Date '3 / b A.« U/ ' <br /> Grout Irwpectlen BY Date Purnp Impaction B <br /> Y DeU <br /> Deatnxilen Impaetien By Date <br /> Cemn,er,t.:U5 -/A"A40 , '• (-�,�. .0 <br /> ACCOUNTING OILY: AUDI FAC# <br /> PE coon FEE INFO AMOUNT RENUTTED C KFICASH RECEIVED BY DATE P9RIUTtSERVICE REQUEST NUMBER INVOICE <br /> 'ASO 1 <br /> I <br /> I ,, <br />