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APPLICATION FOR WELL/PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES } ENVIRONMENTAL HEALTH DIVISION + 304 EAST WEBER AVENUE, STOCKTON, CA 95202 .f (209) 468-3420 N011-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Momplet10 In TTIp0a1tal APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANO10A INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IH COMPLIANCE WTTIf SAN i JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1116.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, JOB AODREBS/OR APNI 14404 E. Hwy 26 CITY PARCEL 612EJAPH/ ! OWNER•BNAME Karl Grupe Ranch ADDRESS 1 4404 E., Hwy 26 Linden I PHONE# CONTRACTORPurviance Drillers Inc. A111B10POBox 64,Linden 1Ci1377923 P ,w.887-3554 SUR CONTRACTOR ADDRESB LICK PHONE/ � TYPE OF WELUPUMP., ® NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER 1 ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J Turb 13 Now❑Rapalr H.P. 60HP DEPTH PUMP SET .2OFT• , FIRST WATER LEVEL O ' (TYPE OF Pt1MPt ❑ OtIT-OF•SERVICE WELL ❑ DEOPHYSICAL WELL! ❑ SOIL BOFUNG a ®DESTRUCTION: fill. from bottom up with 9sac san :.& cement 30ft 14" well INTENDEDUSE TYPE O WELL CONSTRUCTION SPECIFICATIONS (] A ❑ INDUSTRIAL P OPEN BOTTOM DFA,OF WELL EXCAVATION �'1 9 DIA-OF CONDUCTOR CASINO n/a b _ ❑ DOMESTICIPRIVATE ❑GRAVEL PACKISIZE TYPE OF CASINOISTEEUPVC steel- DIA.OF WELL CASINO 16 O -> ❑ P'UBLICAMUNICIPAL ❑DRIVEN DEPTH Of GROUT SEAL 240 SPECIFICATION -250 (`> IMGATIONIAG ❑OTHE11. "ROUT SEAL INSTALLED BY T __._ GROUT BRAND NAME ❑ MONITORING '�,A ( GROUT SEAL PUMPED:jA]�� I' Yr ❑No CONCRETE PEDESTAL BY GRILLER:❑Yr ON. S 1J APPROX.DEPTH ��lfLi LOCKING CHESTER BOX/STOVE POPE g F+I + PROPOSED CONSTRUCTIOR/bRILUNO METHOD: MUD ROTARY_- _X.: __ AIR ROTARY - AUGER CABLE OTHER 1 HEREBY CERTIFY THAT t IIAVE PREPARED THIN APPLICATION AND THAT THE WORK WILL BE DONE M ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWMfR OR LICENSED AOENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH ^5 TMS PERMIT IS ISSUED,1 SIfALL HOT EMPLOY PERSONS SUBJECT TO WORKMAN'!COMP"vATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES 1`•' THE fOLLOWINtP: ''Z IN TIIE PERFORMANCE OF THE WORK Pon WHICH THIS P'ERMTT IS ISSUED,i SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'@ COMMMATION LAWS Of - C A.' HE APPU T MVS ALL 24 HOURS IN ADVANCE FOR ALL REOURED INSPECTIONS AT 12"14010-3422. COMPLETE DRAWINO AT LOWER AREA PROVIDED. Blbnad .c ct i TUI. Corporate Secretary Data 7/13/98 PLOT MAR prow to Seotel Sesto "te 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. ;i EXPANSION OF SEWAGE DISPOSAL SYSTEMS. I J. DIMENSOONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 10. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, ON THE PROPERTY OR AD"INMO PROPO". - _ ;. { J .. . . j1j14. 19 Iaa old w �S c!j.0 c buNTY M 1 G ... a bG. �'�^P�141�1e I; �H (H 0 s iOry ....: :, T ENVIFIONMEN kL HEA IVIS f . - – �' -- .. � .� .- _ -- –T '� DEPARTMENT VSE OM - � �• __ _ _.__ _ - - �- Applleatlen Aeeapted BY 'I Dote T r Mw 7 ek�apeetlen BY I ? bate 73- Pimp Inepeetlen BY Date t V. lnwtlan I.wp:".— !•' Dote Cemrtrenta• ` '7 t ACCOUNTING ONLY; ,AID/ FAC! J PE CODE* FEE INFO - AMOUNT REMITTED Fe /CASH RECEIVED a DATE PERMITISERVICE REQUEST NUMBER INVOICE t 0 01 � a�l t� !O i 1 01 0 s 013 Pub Health Servo-Enviro.173(1/97)