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i ,r APPLICATION FOR WELLJPUMP PERMI- PAYNIF-PT SAN JOAQUIN COUNTY PUBLIC HEALTH SEES RECEIVED ENVIRONMENTAL HEALTH DIVISION P,O, BOX 388, 304 EAST WEBER AVENUF. STOCKTON, CA 9520i3m"p' OV 2 01998 (209) 4883420 5Rti JGApUlN Couly IY NON•REFUNOARI F PERMIT EXPIRES YEAR FgOM DATE ISSUED tlr3:.IC HfAUH SERvICRS 1 NViRONIMNTAL HFAVt-H L)1Vj$j()N 11complets In APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCTAND/on 1ISTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE NrtTH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9.1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC 14FALTIJ SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB AnbRESs/OR APN# 36 North D tree t cmr StoCktori PARCELSI2f/APN# 15 3-1 $0-2$ NER'BNAME Arctic IGe COADDRESS 36 North D Street StaCkPHDNI:,►464-9486 CONTRACTOR V & W 1111 ADDRESS PO liOn 51 T Ri Vz� CN720904 P►roNE.707 3 44_2815 RVB CONTRACTOR ADDRESS LIC# PHONE# TYPE OF WELLIPUMP; ❑ NEW WELL ❑ nEF'LACEMENT WELL ❑ MONITORING WELL# 19 OTHER Borehole ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# ©New❑ J Repelr H.P. DEPTH PUMP SET FT, FIRST WATER LEVEL RYP#pF PUMP1 O ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL IF SOIL BORING EJ 8 DESTRUCTION: Wzt.h neat cement INTENDED USE TYPE OF WE CONSTRVCT1oN 1PECIFICAT10N4 ❑ INDUSTRIAL ❑OPEN BOTTOM DIA,OF WELL EXCAVATION❑© A DPA.OF CONDUCTOR CASINO p OOMEW @TlC/PVATE ❑GRAVEL PACK1612E TYPE OF CASINGISTEEIIPVC PIA.OF WELL CASINO D FVBLIC/MUNICIPgL TT❑ppDRIVEN DEPTH OF GROUT SEAL SPECIFICATION ❑ IRRIGATIoNIAG SAOTHER borehole GROUT SEAL INSTALLED BY GROUT BRAND NAME R MONITORING C GROUT SEAL PUMPED; ❑Yee [I Ne CONCRETE PEDESTAL BY bFYLLER:❑Yaa UN. s APPROX.DEPTH 5O I LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONITRUCITONIDWLIING METHOD; MUD ROTARY AIR ROTARY AUGER_CABLE OTHER I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND 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 VV111CH THIS PERMIT IS ISSUED,I SITALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING! 'I CERTIFY THAT IN THE PFAFORMANChOF THE WOW(POR WHICH THIS PERMIT 13 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORIOMAN'1 COMPENSATION LAWS OF CALIFORNIA.' T NT MV T CA5�1� t"F0 INSPECTIONS AT 12011 4 X423 COMPLETE DRAWING At LOWER RCA PROM O. Started X + It1e Date � PLOT PLAN{Draw to Soelel Seale '!e 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION Of HOUSE SEWAGE DISPOSAL SYSTEM on PROPOSED 2. OUTLINE OF THE PROPERTY,OIVINO DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINE@ AN LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUMORED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AN WALKS, ON THE PROPERTY OR ADJOINING PROPERTY. (see Work Plan DEPARTMENT USE ONLY J �j AppScatlen Accepted By Det• /rtey–` — �Q Aeeo_07T(o Grout Irtapeotlon By bete P e v'In►peellan By Dale Oeatn�ellen Impsrllen By Data ACCOUNTINO ONLY; Alp# FAC# PE CODES FEE INFO AMOUNT REMITTED CHFCK#1CA6H RECEIVED BY DATEPETtAMT/1ETiVICE REQVEIT NUMBER INVOICE Pub.Health Serv.-Enviro.173(3196)