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SAN IWPLICATION FOR WELL/PUMP PERMIT J OUIN COUNTY PUBLIC HEALTH SER&S L)0 X02.S ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUER E-� -' 6- oq (ComplEu In TripDeB1BI APPLICATION IS HERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE W11H SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1116.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APNE IiGG BANTA R D. CTY TRACY PARCEL SIZE/APR/ OWNER'SNAME_A RI M POMBO PARTNERSHIP ADORE966645 !J . DELTA AVE . TRACYPRON11 835-4949 CONTRACTORHENNINGS BROS DRILLING CLINLAIDDRIE993525 PELANDALE MOD Lic/ 290813PHGNE1545- 1185), BOB CONTRACTOR TTpp ADDRESS LIC/ RHONE I Lp �J TYPE OF WELIJPUMP: NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELLI 11 OTHER V ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J HYPE OF PVMPI 13New L3 Rep* H.P. DEPTH PUMP SET-FT. FIRST WATER LEVEL O OUT-OF-SERVICE WELL 11GEOPHYSICAL WELL/ ❑ SOIL BORING S ❑DESTRUCTION- 11 INTENDED USE TYPE OF WELL CONSTRUCTIOn SPECIFICATIONS A p❑RII INDUSTRIAL 11 OPEN BOTTOM VIA.OF WELL EXCAVATION 12"( DIA.OF CONDUCTOR CASING p I(V DOMEBTIC"IVATE W GRAVEL PACK/SIZE TYPE OF CASINO/STEEI/PVC PVC DIA.OF WELL CASING 6 II O ❑ PUBUCRMUNICIPAL ❑DRIVEN DEPTH OF GROUT BEAL 100 1 SPECIFICATION B E N T 0 PJ I T E R Q ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED r yBBY H E N N I N G S GROUT BRAND NAME ..yM E 11MONITORING GROUT SEAL PUMPED:LDY. (IN. CONCRETE PEDESTAL BY DRILLER:❑Yw [AN. 5 APPROX.DEPTH LOCKING CHESTED BOX/STOVE PPE V 5 PROPOSED CONSTRUCTIONIdtlLUX NO METHOD: MUD ROTARY AIR ROTARY AVOER CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE"We,ANO RULES AND 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 FOR WHICH THIS PERMIT IB ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES ' THE FOLLOWING: •1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK POR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA: THE APPLICANT MOOT CALL 24 HOMS IN ADVANCE FOR ALL REOU UM,INSPECTION$R 1 1 ASSJ 2a. COMPETE DRAWING AT LOWER AREA PROVIDED. 9-9-97 PLOT PLAN IDI.w t.Se.1.1 Be fa •to 1. NAMES OF BTREFTS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4, LOCATION OF HOUSE$MADE DISPOSAL SYSTEM On PROPOSED 2. OUTLINE OF THE FYDPERT(,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED TFTY Fl. STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATDS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. ... 17-s ... .... \\ fdt c�a ... ' . :.__ .. :..... . . i.._. . ..... g SEP 30 X997 ... SAN:JU EN SLIC ��lffI ONf; AST`Fu1 ND1IVY 152)N.. :...._... .. . .VIA - IENIA _ .. i .. .. .: .........;......p.....i. ...j ... .y. DEPARTMENT USE ONLY AnPllc.tlan Accented It, cX/Y'�"t.•��-:1--1.--�`' P - p D.t. Grew ImPeeOon BY _ Dae 0 331 Pump In.PecRen By ON�e pi Un.tncllan In.neall B1� .. Q - c .G,4e,) [ 2' !P L}�.So, WiI1 ai.c�C'/7tw12 Ga.-l�i'�Yl.ic h`Uy1 'CF rltY clnl;/ v?� C.crt ctSC �11�c�rJ fptvvl w^*y accounnc I'5L.n� naontr: No# FACT reo(P(' ?✓ PE CODES FEE INFO AMOUNT REMITTEDCHECK/ ASH RECEIVED BY DATE POW11T/SEANCE REQUEST NUMBER INVOICE 9 -se -7 / 0NI8a Pub.Health Sew.-Enviro.173(1/97)