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APPLICATION FOR WELLIPUMP PERMIT —.,N JOAQUIN COUNTY PUBLIC HEALTH SERVICI`-�- ENVIRONMENTAL HEALTH DIVISION P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201.988 (209) 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 WOR(DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPME R ,CHAPTER�-'l A3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICER.ENVIRONMENTAL HEALTH DIVISION. Iq JOB ADDRESSOR APN/_ S_ E _ Corner of RAY/W HWY 12 CITY LOD I PARCEL 81ZE/APNI OWNER'S NAME T n d e r S in g h ADDRESS 4220 W . Hwy 12 1 o d l —PHONE,, 369-601L CONTRACTOR _ Hennings Bros . Drilling Co . ADDRESS 3525 Pelandale Mod LIQ, 290813 PHONE,545- 118 SUB CONTRACTOR ADDRESS UC/ PHONE I _-r• TYPE OF WELUPUMP: A3 NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL R ❑ OTHER ._.� ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL 0 ✓ ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL p-�, (TYPE OF PUMP) ❑ OUT-OF-SERVICE WELL ❑ OEOPHYSICAL WELL/ ❑ SOIL BORING S7U-rt ❑DESTRUCTION: V' INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 1 2 11 DIA.OF CONDUCTOR CASING D K3 DOMESTIC/PRIVATE 10 GRAVEL PACK/SIZE TYPE OF CASINO/STEEL/PVC PUC i DIA.OF WELL CASING 611 DC- 1:1 PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL 10 0 1 SPECIFICATION B e n t o n i t e R r ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY Henn i n g s GROUT BRAND NAME ��yy E�' ❑ MONITORING I — — GROUT SEAL PUMPED. ®Yea [IN. CONCRETE PEDESTAL BY DRILLER:❑Yea 13l 4. 5 APPROX.DEPTH ( �� LOCKING CHESTER BOX/8TOVE PIPE S r PROPOSED CONSTRUCTION/DAILLING METHOD: MUD ROTARY X X AIR ROTARY AUGER CABLE OTHER - I 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 ANp 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 16 ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 16 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OFTTT CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REGLIIR�INSPECTION$AT 12051 4"-S422. COMPLETE DRAWING AT LOWER AREA PROVIDED. rt BIDnW x ; �ti - 1. h �i•Iti -'< Data D F C . 1 9 , 1 9 9 5L-L PLOT N (Drew to Seale)Scale to 1. 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 OUTUNFB AND LOCATION OF ALL EXISTING AND PROPOSED 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED Fir FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. A 70 RV 4 . Al cod ... : .. U rJb IL9.9�1 ~r C .\ \ l :1 IV) �Yq�.rT ... i F 1 . O . evs l stir DEPARTMENT USE ONLY /` Appllcatlon Accepted By l Date Z. l/A .J A," -z_ I a— Grout Inspection By c- Date.-.—A,7- C /G Pump inapectlon By Dole Destruct n IneeCpectlon By Date �r�,✓/4� - /'?/•llr('� 1 ss/'•� - l 45 � YP.-.[_/ /l6� .�S fe(Lc[( . _ Co, enn: c• c.� .}e _4 .-ce r- K.t./c/• f/ 5 �—s.- J]r•lla._s ....t eN S Cf cL 4 G� ,LJI �elr *e -a nee! C-;-_vc11-4 (ate i � � r' � 1-en<vCc' he(cz..l roti io"u.> i We ev e.�eKcr�.•`.� -a.♦ (r. f>C�'�u v t v,��' ACCOUNTING ONLY: AID nc f.v,-/-- FAC( ��+f'a c.k-r✓ LJ d�,C>�r Y" PE CODES FEE INFO AMOUNT REMITTED CHEC /CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE I o �� i S7