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APPLICATION FOR WELLIPUMP PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERV„7E9 PAYMENT ENVIRONMENTAL HEALTH DIVISION `tom P 0 BOX 388,448 N.SAN JOAOUIN ST,STOCKTON,CA 95201.388 RECEIVED (209)488-3420 FEB 2 0 1996 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN JO,`.�I TIN CCIUNTY (Complete In Trlplleete) Ay,PUBLIC HEALTH SI:ItvICES APPLICATION 18 HERE DV MADE TO THE BAN JOAGUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS 617VNr.IgP1'T'CQN 148A1dANCLN'M1FilAA1 JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-11�16.3�A)N�D THE STANDARDS OFSANJOAOUIN COUNTY PUBLIC HE]ALT_14 SERVICE8,ENVIRONMENTAL HEALTH DIVISION. JOB ADORE88pR IA�PNIL `� G Q`4 T M0,Y"V-V; 5 T7 f-VIA- CITY rS`Q IL.V-k-0-1 1,,, PARCEL SIMAPNE OWNER'S NAMECG-4V O 7,SA L.V�✓1 -T� `^ ADDRESS 14(0:5 !7 L�Lk'A W I/�� S4^1-4-1-4-�1 `P ONE E�9 13 7-%4 3$ CONTRACTOR J1AL I n L•1�1'ro�L1 ..1 1 /CL.�� W��. ADDRESS 11100 v 1'4E'll l l.s IJ/A. LN:/ (C/�` P O E f 20 5;c1-z L L l SUBCONTRACTOR Sp<A-'-YJ ^ Dt\��.'F�HL ADDRESS Z% tt(o�R11aNErZo 4145”45-ML -Y1� TYPE OF WEU-WMP: ❑NEW WELL ❑REPLACEMENT WELL ❑MONITORING WELL• •J❑OTHER •✓O(J�J ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CR108S�CONNECT REPAIR ❑VAPOR EXTRACTION WELL E J ❑Nwv❑R.e.l, H.P. DEPTH PUMP 617—FT. FIRST WATER LEVEL O ITYPE OF PVMPI ❑OVT-0F.BERVICE WELL ❑GEOPHYSICAL WELL e ❑ BOR BORING S XDESTRIOTION: timo—couse TY O WELL CONSTRUCTION SPECIFICATIONS i A ❑INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION_ O DIA.OF CONDUCTOR CASING T 1`, O ❑DOMESTIC/PNVATE ❑GRAVEL PACKMZE TYPE OF CASING/STEEUPVC DIA.OF WELL CASINO 2M O 13PUSLIC/MUNICIPAL 13 DRIVEN DEPTH OF GROUT SEAL _ SPECIFICATION L�\ LW 4 ❑1 DATION/AG ❑OTHER GROUT SEAL NSTAl1E0 ey_-VI�tJ '*j V -0 l.lrOr GROUT BRAND NAME CYIV.N(• p(AIdJFp� 1 N to VHG L GROUT SEAL PUMPED:IRU Yr ❑Ne CONCRETE PEDESTAL BY DRIUFR:❑Yr ism. S APPROX.DEPTH Ss� LOCKINO CHESTER BOXMTOVE PIPE S PROPOSED CONSTRUCTI HUDIBWNO METHOD:MUO ROTARY AIR ROTARY AUGER_CABLE OTHER 1 HERESY CERTIFY THAT 1 HAVE PREPARF.O THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAGUIN COUNTY ORDINANCES,STATE LAWS,AND RUES AND REGULATIONS OF THE SAN JOAOUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED.1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUPORMA.'CONTACTOR'$MIeNG OR MM-CONTRACTNG BONATURE CV"IFE8 THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUF017BA.- THE APPUCANT MUST -CALL 24 TOURS IN ADVANCE FOR ALL REOUIRED IIINNSSPET:TIONS�AT I20e14064.22.COMPLETE DRAWING AT LOWER AREA PROVIDED. so-i (C)l M L /�1�7'1Vi TRI.Pr,!,UL ..JV P�V'1`� T FLAN ID.wv le SeYH 'te 'IOM ATTQL,1—A. 41St E'•1L�JL /.NAWe OF STREET$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 EX19TIMi AND PROPOSED S.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUD04 COVERED AREAS SUCH AS PATIOS.DRIVEWAYS,AND WAlX6. ON THE PROPERTY OR ADJOINING PROPERTY. Z 10 �O II C xu LN y T yI SW.- LJ LJ iEi c `'t E V/L SIOPI MAW LEGEND: S V- MONIIORING WELL Ip AI SOIL SAMPLE (6/9/86) SITE PLAN SHOWING PPODUCI LIIIES TRENCH SOIL SAMPLE LOCATIONS - STOCKTON POLICE STATION - — - VAPOR RECOVERY PIPE STOCKTON, CALIFORNIA DEPARTMENT USE ONLY Ap.Se.Gen Aeaeltl BY- - D.I. 3.12- + A,-' 2 areal B�ft.Br Dm-. Pump I--PUSS 8Y Dn. Die oNe InP.e len er DH. cemm.nH: ACCOUNTING ONLY: MDI iAGS PE CODES FEE INFO AMOUNT REMITTED CHECK//CA8H RECENm BY DATE PESMBTISIDIVICE REQUEST NUN661 INVOICE °a72 9D MA 3.1.2 (o p