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APPLICATION FOR WELLIPUMP PERMIT %�aAN JOAQUIN COUNTY PUBLIC HEALTH SERV ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOADUIN ST., STOCKTON, CA 96201.388 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROU DATE ISSUED (Complete in Triplinto) 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 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN# 5451 East Harding Way Stockton CITY PARCEL SIZE/APNF OWNER'S NAME KJAX Radio Station - FEMA ADDRESS 110 North E1 Dorado St, Sp && �ton coNrRAcroR Woodward-Clyde Federal Services g ADORES S1� PHONE 8-0 9 H H 91G- SUBCONTRACTOR EN PROB ADDRES6E)'0. BOX s #C-57 (NA)PH NE#&onnT TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMP) , 11 OUT-OF-SERVICE WELL 11 GEOPHYSICAL 1� YSICAL WELL# tis)JOIL BORING ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL(PVC DIA.OF WELL CASING D ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL 601 SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY Tremmie Pipe GROUT BRAND NAME E '{MONITORING GROUT SEAL PUMPED: ❑Ys ❑No CONCRETE PEDESTAL BY DRILLER:❑Ys XqWo S APPROX.DEPTH— 6 O 1 LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER Direct Rush 1 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 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 CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAR'6 COMPENSATION LAWS OF CALIFORNIA." E AP C NT MUST CPU 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION$AT(2091468-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. Signed Title Geologist Date 3-15-95 Bill Loskut ff PLOT PLAN(Draw to Scale)Suls "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 OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. 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 Attached Map PAYMENT... _'. . RECEIVED D MAY 1 7 1995 SAN JOA /ulYy CCUN! PUBLICHEALT4 SERVICES ENWRONMEN'TAL HEALTH QM%,- DEPARTMENT USE ONLY Application Accepted By So Date ."J�I / Arca Grout Inspection By Date Pump Inspection By Date Destruction Inspection 8y Date ccgrnments' ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTEDCHEC ASH REC'VYEP E PERMIT/SERVICE REQUEST NUMBER INVOICE Z061 .DU -To © (�05