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APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION f <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> ROP-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete M Triplicate) <br /> APPLICATION 19 HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WRIT SAN <br /> JOAOUIN COUNTY DEVELOPMENT TALE,CHAPTER 9.1115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY P/SUC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDREB&OR APN/ MEDINA V(OOD PRODUCTS/26342 S. BANTA RDSITY TRACY IPARCEL 6REUPNF <br /> OYMER'S NAME MEDINA WOOD PRODUCTS ADDRESS P.O. BOX 1037 TRACY PHONES 832-4523 <br /> CONTRACTOR HENNINGS BROS. DRILLING CO. INC. AODRESS 3525 PELANDALE MORD/ 290813 PHONE/ 545-1185 <br /> RUB CONTRACTOR , ADDRESS UC/ RHONE/ <br /> TYPE OF WELL/PUMP. LJ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J <br /> ❑N. El Pqm' M.P. DEPTH RUMP BET—FT. FIRST WATER LEVEL O <br /> HYPE OF R/MPI <br /> ❑ OUTOF-SERVICE WELL ❑ GEOPHYSICAL WELL/ ❑ FOIL BORINO R <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONSNN y1I A <br /> El <br /> INDUSTRIAL p❑pyVO"PEN BOTTOM CIA.OF WELL EXCAVATION DR 1211 DIA.OF CONDUCTOR CASINO D <br /> .�Vlt DOMEq.P{H <br /> STICIPIVATE RAVEL PACK/SIZE TYPE OF CASINO/STEEL/PVC PVC DIA.OF WELL CASINO 611 C <br /> �y R1BlIC/MUNICIPAL �❑DRIVEN� DEPT H OF GROUT BEAL 1001 SPECIFICATION BENTONITE R <br /> ❑ IRRIGATION/AD LJ oTHEn UT SEAL INSTALLEDBY <br /> [IN. <br /> H NN I NGS BMW BRAND NAME AAryry E <br /> ❑ MONITORING n7 GROUT SEAL PUMPED:61 Yw Ne CONCRETE PEDESTAL BY DRILLER:❑Y.. MN. S <br /> APPROX.DEPTH 1801 !� LOCKING CHESTER BOXISTOVE RPE <br /> X <br /> 5 <br /> PROPOSED CONI TRUCTIONIDRILUNG METHOD: MUD ROTARY X AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL HE DONE N ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAOUN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWNO:'1 CERTIFY THAT N THE PERFORMANCE OF THE WOR(FOR WHICH <br /> THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAM OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: •1 CERTIFY THAT N THE PERFORMANCE OF TILE WORK FOR WHICH THIS PERMIT 18 ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'e COMPEFJIATION LAWS OF <br /> CALIFORNIA.- THF APPLICANT MUST CALL 2 <br /> C4 MURI IN ADVANCE FOR ALL REOUIMM 1NSMDORG AT IMI 4011,5423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> 9liryrtl x�-1'omR.,L'1v—tet .5,7141.. \ lns_`� �., 'co Tir, Q.ctY— (TAAA,. D.I. SEPT. 22, 1998 <br /> not MN ON.1.So.l.)Bo.l. le <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE FEOPERTY. I. LOCATION OF MUSE BEWAGE ouvom SYSTEM OR PROPOSED_____—..... <br /> 1. OUTLINE OF THE PROPERTY,GIVING DIMENSIONG AND NORTH DIRECTION. <br /> 140FBEWASE.OIePOeu's98TEMB: —__ <br /> ]. DIMENSIONED O 191Sro.A1Tp'RROPOBEC' S. LOCATOR OF WELLS WITHIN MONS OF ONE HUNDRED FIFTY R. <br /> AYRYKT RS, L <br /> COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WMx9. ON THE FTOPERTY OR ADJOINIMO PROPERTY, <br /> PW s A-A- <br /> lpm <br /> J <br /> J <br /> I <br /> ill <br /> OCT 2 1998 <br /> DEPARTMENT USE ONLY ^ y// <br /> APPllc.11en Av WIM BY L ✓ O At. �/ N <br /> Ore.Imeeelbn By II D.n /d-ZZ-1pp0 Pune lmP.etlen By <br /> D.b <br /> OMbmllen I tbn y O.t. <br /> f <br /> � e� l� <br /> �7AAm <br /> t <br /> SE OAy c <br /> r <br /> ACCOUNTING ONLY: AIDE FACT 0, <br /> PE CODE/ FEE INFO AMOUNT REMITTED C C I/CASN RECEIVED BY DATE PERMITItpUVICF REOVEST NUMBER INVOICE " r <br /> o05D G . <br />