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11 _< APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES f ENVIRONMENTAL HEALTH DIVISION. Py P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON,CA 86201.388 (208) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1116.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,-ENVIRONMENTAI.HEALTH DIVISION. ! JOB ADORESSIOR APN' 59H 1� L I N N E R D. cITM T R A C Y PARCEL SIZE/APN? owNE=1i'8 NAME_- B _Z N _ -7.2,2S -0 _ PHONE l CONTRACTOR HCNNI-NGS BRAS. DRILLING CO- ADDRESS 3525 PELANDALEMOD,49,r5n3.56� P'11oNE?545-1185 - SUB CONTRACTOR._ - , _- ADDRESS LTC?08.1 3 PHONE TYPE OF WELLlPUMP: ❑ NEW WELL M REPLACEMENT WELL ❑ MONITORING WELL? ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL? jj ❑New❑Rapsir H.P. DEPTH PUMP SET : FT: FIRST WATER LEVEL 0 (TYPE OF PUMP) 4 - ❑OUT-OF-SERVICE WELL. ❑ GEOPHYSICAL WELL? ❑ SOIL SOWNG g DESTRUCTION: _INTENDED USE TWPWELLCONSTRUCTION SPECIFICATIONS A ��❑0 INDUSTRIAL Ip❑t OPEN BOTTOM DIA.OF WELL EXCAVATION II DIA.OF CONDUCTOR CASING D /4.IL PW DOMESTICIVATE ❑GRAVEL PACKISIZE TYPE OF CASINGISTEELIPVC Pyr DIA.OF WELL CASING .6" D ❑ PUBLICIMUNICIPAL 13 DRIVEN DEPTH OF GROUT SEAL_ 10,0 �W, SPECIFICATION--trtrt6 V S C h R ! ❑ IRRIGATION/AO ❑OTHER GROUT SEAL INSTALLED BV__,++H��F'N N„I U G S GROUT BRAND NAME p��7 i ❑ MONITORING GROUT SEAL PUMPED: Q Vie IN No CONCRETE PEDESTAL BY OMLLFI:❑Ys KIN. S APPROX.DEPTH LOCKING CHESTER BOXISTOVE PIPE - g PROPOSED CONSTRUCTIONIDWLLiNO METHOD: MUD ROTARY X'_ AIR NOTARY AUGER: CABLE OTHER e I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND f 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 SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORN(A.' CONTRACTOA'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE-OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURb IN ADVANCE FO AEQ RED 1NSMTIONS AT(20111)4653423. COMPLETE DRAWING AT LOWER AREA PROVIDED. 6. 5-95 —� 619ned X t Osta 0 ' PLO PLAN ale)Sole T. 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,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. �..,1,�• STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, ON THE PROPERTY OR ADJOININ13 PROPERTY, .mow :..,.. .......:.......:..... ; ......... ......... .. ..............., I ........ . . ... r o b . (' .... ......'. ..k :... .. :,... ..........., . . ... .. ... :�� .. i PAYMENT ��++ -1D D b � R� i ..... .. .. . :... . JINN ..�� 5.... .._' .......... .,.. BAR! JOAGUf14. f3l f . ....... ... ...... U/ F l 111 HEA DEPaarMEH -E o - - TA L -F fvl�J. -HEAD T-H�lvta o v; YT Ute NLY' Application Accepted By Date : 'A,, l Cell Grout Inspection BY - _ - - - = ZT. Aump'tNip3�tion BY - - .. .Destruction Inspeation 8y jj pQ Date Commems: le n f�1 TmLS 1�.Cr/ ate' I C-0 I i fin i 5 G i�. c�jlrl if�5 ` .S �5 o v1 wi [ ' i.�iJcl'2�-f ACCOUNTING ONLY: AID{ - FACIA 3 0- vy �-r� -3� PE CODES FEE INFO AMOUNT REMITTED EC !CASH RECEIVED BY DATE PFAMITISFAVICE REQUEST NUMBER INVOICE L t LA 6 i Z 3 Z O 3 r I