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r� �U -070 -o � APPLICATION FOR WELL/PUMP PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 MON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In Trlplicels) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER$-111 S.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, JOB ADORESSIOR ATN, 20750 S. N A G L E E RD . CITY TRACY PARCEL SIZEIAPNN OWNER'SNAME TONY AVILA ADDRMee 20750 S. .NAGLEE. RD. TRACY p„QNE;832-8613 cawRox-roR HENNINGS BROS. DRILLING CO. INC. ADOREes 3525 PELANDALE MORx,T 290813 PHONE, 545-1185 SUB CONTRACTOR �,y�y.� ADDRESS AJC, PHONE 4 TYPE OF WELLMUMF: NOF NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL, ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIA ❑ cRDes-cONNECT REpAiR ❑ VAPOR EXTRACTION WELL, 4 ❑NOW❑Rr1611 H.P. DEPTH PUMP OFT FT. FIRST WATER LEVEL. O RI YPE OF PUMP) ❑ OUT-0FSERVICE WELL ❑ GEOPHYSICAL WELL, ❑ SOIL BORING B ❑DESTRUCTION. INTENDED USE TYPE OF W _ CONiTRUC710NiPECIFICATIONe .H A R❑ INDUSTRIAL (,3 OPEN BOTTOM DIA.OF WELL EXCAVATION 1 2 11 VIA.OF CONDUCTOR CASING O ICJ DOMESTICIPRIVATE 91 GRAVEL PACKISIZE TYPE OF CASINGISTEELlPVC PVC _ DIA.OF WELL CASINO 611 a ❑ PUBUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL 1 00 ' SPECiF1CAT10N S E N T 0 N I T E 4 ❑ IP"OATIONIAG ❑OTHER GROUT SEAL INSTALLED BY H F N N T N r S GROUT BRAND NAME E ❑ MONITORING n GROUT SEAL,PUMPED: M Yes [I We CONCRETE PEDESTAL BY DRILLER:❑Yr M Ne S .� APPROX.DEPTH 200 0 1 LOCKING CHESTER BOXISTOVE PIPE S (`~ PROPOSED CONSTRUCTIONIDRILLING METHOD: MUD ROTARY X ARR ROTARY AUGER CABLE OTHER 1 I HEREBY CERTIFY THAT 114AVE PREPARED TRIS APPLICATION AND THAT THE WOW 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 714E PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 16 ISSUED,1 SHALL NOT EMPLOY PERSONA SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SU"ONTRACTMG SIGNATURE CERTIFIES THE F -1 CERTIFY THAT IN THE PERF RMANCE OF THE WORD FOR WHICH THIS PERMIT 19 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF ` CALIFORNIA.' T APPl1CANT MUST CALL 24 IN ADVANC FOR ALL REQUIRED INePECT ON T t2oe1 4".24I7.�COMPLETE DRAWING AT LOWER AREA PROVIDED. � O*wd X Title 7��/1J . D.t. O C T. 12 , 19 9 8, PLO N(Waw to Bowel Bede 'to I. NAMED OF STREETS OR ROADS NEAREST TO OR BOUNDI HE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED (L` 2. OUTLINE OF THE PROPERTY,04V*M DIMENSIONS AND NO H OHRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS. J. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RAMS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDINO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOININO PROPERTY. .. ...... 1� Ar n y '. p / --=---�-'--'--'- ---' --- arm . -� - NU1r 5 .1998.1 . gl .. ...... .. Co.t•r.a l 1 t DEPAR .� . APFlieatlen Aeoepted BY AZia— - Date Ar.. Grout kopeetlen BY Date Z�F � Purnp Inroeotlen BY Dote De.tremtler.kwp Ikrn y ^L - Dole Co--er e..IZ^ ! E pir Icy— ACeol1NTING ONLY: AID/ FAC, PE CODES FEE INFO AMOUNT REMITTED ECK AIIH RECEIVED BY DATA �y PERMITISFRVICE REQUEST NUMBBti! INVOICE I Pub Health Serv.-EnViro.173(1197)