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wm*"f APPLICATION FOR WELLIPUMP PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PX 388,304 EAST WEBER AVENUE,STOCKTON,CA 95201.88';IT ,I iV (209)468.3420 A�,►�' NOW-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In Triplicate) I APPUCATIO'�y1y�'{� MADE TO THE SAN JOAQUIN COUNTY FOR A PERMfT TO CONSTRUCT AND/OR IN6TALL THE WOR(DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN 1 JOAQUIN COUI�'/'DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. JOB ADDRES91OR APNa 7298 EAST HIGHWAY 12, L OD I, CA 95240 Clri PARCEL SIZF/APNI 055-150-18 CHARLES NEIER ETAL 6597 LANSING COJRT, PLEAS.ANTON, CA 925 846 0897 OWNER'S NAME ADDRESS PHONE! 1 CONTRACTOR_ EARTHTEC,LTD. ADDRESS 1830 VERNON ST k7, ROSEVt6E, CA 95678�NEg916 786 5262 408595 SUBCONTRACTOR ADDRESS LICA PHONES 1 TYPE OF WELLTUMP: ❑NEW WELL ❑REPLACEMENT WELL ❑MONITORING WELL 0 ❑OTHER ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSSCONNECT REPAIR ❑VAPOR EXTRACTION WELL 0 J ❑Nov 13 F.PM, H.P. DEPTH PUMP SET__---FT. FIRST WATER LEVEL O iTYFE OF PUMP( GEOTECHN I CAL ❑.OUT-Or-SERVICE WELL ❑GEOPHYSICAL WELL N � SOIL BORWO S ❑DESTRUCTION: one bor I ng t& 2034)1 1 INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑INDUSTRIAL ❑OPEN BOTTOM 010.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D ®DOMEATIC/PRIVATE ❑GRAVEL PACKfAIZE TN-'F OF CAA1NG.'STEE1RVC _ Q-A-OF WELL CASING 0 ❑PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R 1 ❑IRRIGATION/AG ❑OTHER��II �� GROUT SFAL INSTALLED BY GROUT BRAND NAME E ❑MONITORING g°^J 36 1 GROUT SEAL PUMPED:❑YM ❑N. CONCRETE PEDESTAL BY INLLEA:❑Yoe ON. S APPROX.OE7TN z s "/d`+ LOCKING CHESTER BOXISTOVE RPE S PROPOSED CONSTRUCTIONIDPoLLING METHOD: MUD ROTARY AIR ROTARY AUGER X CABLE OTHER 1 1 HEoEeVULATIONS OF THE SCERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGAN 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 WORKC MAN'S COMPENSATION LAWS OF CALIFORNIA.-CONTRACTOR'S HIRING OR SUBCONTRACTING 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 WORXMAN'S COMPENSATION LAWS Of CAUFORNIA.' THE APPUCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REGUIRID INSPECTIONS AT 1201111400-3493.COMPLETE DRAWING AT LOWER AREA PROVIDED. 1 Sla..ax �cj 4. iiK _ Thl. PRINCIPAL CONSULTANT Dueo 10/28/99 ROT PUN ID—to Sonia)6-10 °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. 1 3.DIMENSIONED OUTUNFS AND LOCATION OF ALL EXISTING AND PROPOSED G.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. SEE IUTACA a . 1 r.....:......: ....... 1 :. .. s.. .; ..t.... �............ ........... t-.... ..<.... ;.. . FIEC .................. ... .'.....i..__.p......: ..... ..' _. SAN vFL(tJIN .1.Ew 1 ...._;.... ,. .,....•o.._:.....:.....:.. ........ ENVRONMgNTA�HEALTA 01 SIQN �\ OEPAIR T USE ylA9pll—l—A..e wd BY C- r Arm �• 1 GION lmp-1, Dote P—P I-P.11-8Y C� Data ea DUUellon Irrepeotton B Dat e ` Commea.=• 1 ACCOUNTING OHLV: A. FACd PE CODES FEE INFO AMOUNT REMITTED HEC (CASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE