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APPLICATION FOR WELLIPUNIP PEl?`7 SAN JOAOU1N COUNTY PUBLIC HEALTH :._Avb__J ENVIRONMENTAL HEALTH DIVISION P.O. BOX 3$8,304 EAST WEBER AVENUE, STOCK ON, CA 91M opy (209) 468.3420 fir NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED ; ICompkt9 In Triplintd APPLICATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-111 S.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDREBSlOR APNI 530'0 L E H M A N RD . CITY TRACY PARCEL 812FJAPN/ OWNER'S NAME RALPH RUTS ADDRESS 5300 LEJJMAN RD. TRACY PHONE, 835-1453 CONTRACTOR H F rd N I N r,S R ROS _ U R I I t, j U G C 0. ADDRESS 3525 PFl AMMF, h 95356ucir 290813 PHONE 1545—1 18! BUS CONTRACTORp�- ADDRESS LIC* PHONE PE TYOF WEU DMP; 13E NEW WELL XREP LACEMENT WELL ❑ MONITORING WELL it ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL9 J ❑N.❑Repair H.P. DEPTH PUMP SET FT, FIRST WATER LEVEL Lt RYPE OF P'UMPI ❑ OUT-OF- ERVICE WELL ❑ GEOPHYSICAL WELL I ❑ BOIL BORING gE p�� f 06ESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS - A ❑INDUSTRIAL C1 OPEN BOTTOM DIA.OF WELL EXCAVATION 12 11 DIA.OF CONDUCTOR CASING p .93-DOMESTIC/MVATE GRAVEL PACKISi2E TYPE OF CASINGISTEEL/PVC R V C RIA,OF WELL CASING 6 it D ❑ PUBUCMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL 100 1 SPECIFICATION 8 E N T 0 N I T E R 0 IRRIGATION/AG ©OTHER GROUT SEAL INSTALLED BY HENNINGS GROUT BRAND NAME E, ❑ MONITORING - I GROUT SEAL PUMPED: ❑Yea IL,1I No - CONCRETE PEDESTAL BY DRILLER:❑Y. #tl"ne'�*+� APPROX.DEPTH ' 5 LOCKING CHESTER BOXISTOVE PIPE PROPOSED CONSTRUCTIONMRILUNG METHOD: MUD ROTARY X X AIR ROTARY AUGER CABLE -OTHEIL__._-- I HEREBY CERTIFY THAT Y HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL HE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND l 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 IS ISSUED,I SHALL NOT EMPLOY PERSONS eUBJEGT TO WORKMAN',COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHAH EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION4 AT 12091 499.7!423. COMPLETE DRAWING AT LOWER AREA PROVIDED. el,nad X Title D.,, '10-1.8-95 PLOT PLAN[Draw to Basis)Boal* to I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GRANO DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS, . 4 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. - STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. or i ...... ..i. ... .... .... .. v ` G .., .....,...,. ym a:.. ., -OCT 1-:9,i9 SA JPA6'UIN C,C)UN i PUBC ;HI=ACTH bIMRVICES ..� i ENVif�ONMENTAL HEALTH:DIU151bN N.1 : tiv:t71 ,._ .. rk n . _DEPARTMENT I EONLY G Applleation Accepted By Do te Arw jr Gtout Inspection By �• Date -0 45 Pump Inspection BY Det* Destruction Inspection By Date `3$ Comment@: OT <� Y 0-4— ESEwA44 rcp c— IE yn: 7�7� r 'rQ ITE 'rf OA F_ ACCOUNTING ONLY: AID# FAC/ PE CODES FEE INFO fq!94D UNT REMITTED CHEC" ASH RECEIVED BY DATE PERMITISSINACE REQUEST NUMSER INVOICE X70 ,oa 9 3 la 14 q D 3lPo 0 Oa3loti