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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERI PAYMENT T, ENVIRONMENTAL HEALTH DIVISION P,O. BOX 388, %4 EAST WEBER AVENUE, STOCKTON, CA 95201 E I VE D (209) 468.3420 I A N 2- 3 10;116 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN JO., �).lIN �;+�I.INTY (Complete in Tripikata) f'L OIX HEALTH RVICES APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBE�NTHISA PPLI AfION IS MAD IN�COMPITAACE 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# 1444 South Lincoln Street CITY Stockton PARCEL SIZE/APN# OWNER'SNAME San Francisco French Bread Co . ADDRESS 7801 Edge mter Dr. , Oakland pHONEs(5n/10)568-5511 CONTRACTORInc. AODRESS90 New Montgomery StLIC# P..,,,,415/88215481 5/882 1 548 SUB CONTRACTOR Mitchel l Drilling Env. #620 ADDDASS P.0 Bx.2231 ,�# 672617 PHONOd6/8529558 am n Cordnva TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL is MONITORING WELL# MW-1 ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J 11New 11Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0 (TYPE OF PUMP) ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING R ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 8 inch DIA.OF CONDUCTOR CASING 0 11DOMESTIC/PRIVATE ®GRAVEL PACK/SIZE TBD TYPE OF CASING/STEEL/PVC PVC DIA.OF WELL CASING 2 inch 0 ❑ PUBLICMIUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL e t SPECIFICATION a Bentonite R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY Mitchel I GROUT BRAND NAME }} E CR MONITORING GROUT SEAL PUMPED:Jq Yes ❑No CONCRETE PEDESTAL BY DRILLER:w Yes ❑No S APPROX.DEPTH 50 feet LOCKING CHESTER BOX/STOVE PIPE Box 5 PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER_CABLE OTHER I HE9EBY CERTIFY THAT 1 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 SUB-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'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 1200`)4^"-3423. COMPLETE DRAWING AT LOWER AREA PROVIDE.. c, Signed X Title PLOT PLAN(Drew to Seale)Scala '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 Attachment.. ... . . / DEPARTMENT USE ONLY Applieatlon Accepted 6y �..i^��r� � �W�� Date— I/7 Area_ Grout Impaction By Date Pump Inspection By Date Dmtructlon Inspection By �/��/�' Date '/�-y� j�,- Comments: K LJ Y/�3— l/V., l7"�'� I I.1 V W (U 1 140 U-7�Tq 5 Y a✓�'Y, (z�1� O 1 1 U L\A �i u3Wj_G. 1 ACCOUNTING ONLY: AID# FAC# 3 S O) PE CODES FEE INFO OUNT REMITTED CHECK#ICASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE )(v ( 3