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� APPLICATION FOR WELLIPUMP PERMIT „s AN JOAQUIN COUNTY PUBLIC HEALTH SERVIA y '>0 ENVIRONMENTAL HEALTH DIVISION P.O. BOX 988, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 488.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED _ ICompNtE in Trlpliutol APPLICATION 16 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN-. JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9.1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APNR 27337 S . BANTA R D . CITY TRACY PARCEL SIZEIAPNR OWNER'S NAME HAL ROBERTSON ADDRESS 27337 S . BANTA RD . TRACYPIIER 832-8827 .+ CONTRACTOR HENNINGS BROS DRILLING CO . , INCADDRE863525 PELANDALE MOD UG 290813 PHONE.545-1185: SUB CONTRACTOR ADDRESS UC:* PHONE l TYPE OF WELLIPUMP: ❑ NEW WELL kA REPLACEMENT WELL ❑ MONITORING WELL R ❑ OTHER •", ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ ( jV New Reptlr H.P. DEPTH PUMP SET_Fr. FIRST WATER LEVEL F.Q' ❑ ❑ TYPE OF PUMP) ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL R ❑ SOIL BORING ❑DESTRUCTION: i=141 INTENDED UEE TYPE OF W ELL CONSTRUCTION SPECIFICATIONS 1211 DIA.OF CONDUCTOR CASING 99❑--VV INDUSTRIAL ❑OPEN BOTTOM DIA,OF WELL EXCAVATION_ )a DOMESTIC/PUVATE ®GRAVEL PACKISIZE TYPE OF CASINGISTEEL/PVC PUC DIA.OF WELL CASING 611 D 1' Jos' n ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL sem-SPECIFICATION B E N T O N I T E : ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED �FR--BTY� H F N N T N 6$ GROUT BRAND NAME rryy,, ❑ MONITORING GROUT SEAL PUMPED:,LAY. ❑No CONCRETE PEDESTAL BY DRILLER:❑Yr In N. S: APPROX.DEPTH 7 / LOCKING CHESTER BOXISTOVE PPESi PR0106FD CONSTIIIICTONmNWNG METHOD: MUD ROTARY X X _AIR ROTARY AUGER CARIE OTHER 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES ANI REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICI THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIE THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUB.IECT TO WORKMAN'S COMMIIATION LAWS 0 CALIFORNIA.- THE APPLICANT MUST CALL 24 RIGORS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12") JA23. COMPETE DRAWING R LOWER AREA PROVIDED. 11 -22-95 . p _ ata x PLOT PAN ID,.to Scalo Scala U 'to 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PWPoBEO 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY�FT.;},'. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED ON THE PtOPERTY OR ADJOINING PROPERTY. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. I }i \ T2 r - _.. _.._. 0 n a w Z, F o '� ala a .. . 1 a` ! hi ...... C ;.._ 14 i'J�sY@N F r. 7 199 GEILIC.M.SALIh gIEHVICES e aNvIkO61 E/VTAI HEALTk"DIVISION: n ♦j�$� /�y�,,,, y�, � DEPARTMENT USE ONLY Application Accepted ByT� y2 txl'rk'Kt`^I`v4,''adiDKat.a Ar re. IrnppctloA4F f7I�ANmP ntp%Von'Sy . Data G oµ x e N,TF:¢Ostrmt1oh i p llp By mF U• Gate Commenu: 0• v ( I ACCOUNTING ONLY: AWN FAG PE CODES FEE INFO AMOUNT RMITTED NEC CASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE 3 l8D 9789 a8 9I 5n 0a a 8'