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APPLICATION FOR WELL(PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388,446 N.SAN JOAQUIN ST,STOCKTON,CA 96201.388 (209)4683420 NONREFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED ICemPlate In Triplicate) APPLICATION 18 HERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.74I8 APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1116.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOBADORESSIORAPN, 2041 Navy Drive CITY Stockton PARCEL SIZE/APNI OWNER'SNAME Milan Mandaric ADDRESS 2150 Berin Dr. San JoraE, CA, 95131 CONTRACTOR Woodward-Clyde 1A RESS� P cv . R UC, PION,,9163680988 SUBCONTRACTOR Spectrum Exploration ADDRESS282.3 E. Myrtle 1JC,612268 NG.,,2094658712 h==Loa- TYPE OF WELL/PUMP. ❑NEW WELL ❑REPLACEMENT WELL ❑MONITORING WELL I ❑OTHER ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL I J ❑N—❑P-P H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O INPE OF PUMPI ❑OUT-OF-SERVICE WELL ❑GEOPHYSICAL WELL I ❑ BOR BORING B ®OESTRUCTION, Existing Monitoring Wells INTEN0ED 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/STEELI VC DIA,OF WELL.CASING O ❑PUBLICRAUNIOIPAL ❑DRIVEN DEPTH OF GROUT SEAL 8PECIFICATION B ❑IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑MONITORING GROUT SEAL PUMPED:❑Y— ❑Ne CONCRETE PEDESTAL SY DRLLER:❑Yw ON. 5 APPIOX.DEPTH LOCKING CHESTER BOXISTOVE PPE S PROPOSED CONSTRUCTIONAINWNO METHOD:MUD ROTARY AIR ROTARY AUGER x CABLE OTHER I HEREBY CERTIFY THAT 1 HAVE PREPAAFD THIS APPLICATION AND THAT THE WORK WALL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES ANO 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 18 ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS Of CALIFORNIA.-CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORSUMAN-S COMPENSATION LAWS OF CALIFORNIA.' THEAPPLICANTMUST C LL 24 HOURS IN AOVANCE FOR ALL REQUIRED INSPECTIONS AT I20SI 4400422.COMPLETE DRAWING AT LOWER AREA PROVOED. SI.—dX 1. \ -� TIP. Geologist �3iTIilos k ut PLOT PLAN ID—to 8W0 84.1. 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 6.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY R. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALK$. ON THE PROPERTY OR ADJOINING PRDPERTY. C r-C See Attached Map PAYMENT RECOVED MAY 17 1995 SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION DEPARTMENT USE ONLY Applla.tbn AoeptM BY D.te �' / "F / M.. Gtote Imp.ellen BY D.I. Pum,I-0—BY D.t. Owtruptlen InFpaetlen BY ONa CommaneF: ACCOUNTING OMLV: AIOI FACT PE CODES FEE INFO AMOUNT REMITTED CHEC ASH RE aY DATE POWAT/SENVICE REOUEST NUMSER INVOICE Y PTD }