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APPLICATION FOR WELLIPUMP PERMIT JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388,446 N.SAN JOAOUIN ST,STOCKTON,CA 96201-388 (209)4683420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICamPMta In 71i aeatBl APPLICATION IB HERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A MMMT TO CONSTRUCT ANDAOR INSTALL THE WORK DESCRIBED,THIS APPLICATION IB MADE IN COMPLIANCE WrrH BAN JOAOUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SEM.,<EB,ENVIRONMENTAL HEALTH DIVISION. JOBADDRESSMMAPNI 2041 Navy Drive _CITY Stockton -PARCEL SIZE/APHI OWNER'SHAME Milan Mandaric ADDRESS 2150 Berin Dr. San JoraEI CA 95131 CONTRACTOR Woodward-Clyde lAADDDRE S C P cv. R LIOI PL,DNE19163680988 euecoNrnAcroR Spectrum Exploration A,D_BB282 E. Myrtle LICb12268 PNoNE.2094658712 LIJL TYPE OF WELL/PUMP, ❑NEW WELL ❑REPLACEMENT WELL ❑MONITORING WELL I ❑OTHER ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSSCONNECT REPAIR ❑VAPOR EXTRACTION WELL ❑N—❑P.", H.P. DEPTH PUMP SET_FT. FIRST WATER LEVEL 0 IT1'PE OF PUMP) S ❑OUT-OF-SERVICE WELL (]OfOPF1Y81CA1 WELL/ WR BORING 10 DC9TRUCTION: Existing Monitoring Wells INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑INOV9TRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA OF CONDUCTOR CASING D ❑DOMEVXIPMATE ❑GRAVEL PACKMZE TYPE OF CASWGMTEELIPVC DIA OF WELL CASINO D ❑PUSLICAEUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL EPECIFICATMN A ❑IRNOATIOH/AO ❑OTHER GROUT SEAL INSTALLED SY GROUT BRAND NAME E ❑MONITONNO GROUT SEAL PUMPED:❑Yw ❑N. CONCRETE PEDESTAL BY DRILLER:❑Y- ❑N. S APP OX.DEPTH LOCKING CHESTER SOX/STOVE RPE S pROFOSED CON9TAUCTIONlDRIWNG METHOD: MUD ROTARY - AIR ROTARY AVOER X CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WRL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'$SIGNATURE CERTIFIES THE FOLLOWING:'I CERflFY THAT W THE PERFORMANCE Of THE WORK FOR WHICH THIS PERMIT IB ISSUED,1 SHALL HOT EMPLOY PERSONS SUBJECT TO WOAKMAN'B COMPENSATION LAWS OF CALIFORNIA.,CONTRACTOR'S HIRING OR SUB-CONTRACT010 SIGNATURE CERTIFIES THE FOLLOWING: •1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,1 SHALL EMPLOY PERSONS SVWECT TO WOIVOMAN'S COMMSAT10N LAWS OF CAUFORMA•THE A►RJG T MUST C 24 HOURS IN ADVANCE FGR ALL FEOUINED INSFCCTIONS AT(209)4 422.COMPLETE DRANAHO AT LOWER AREA PROVIDED. St,,.dX TJ. Geo10gi st 13111 Lj0SKU1C:CPLJL MDT ULAN IDr«.Ie Bo.l.l BuI. •I. 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 IY STEMS. G.DIMENBIOHED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY Fr. STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WALKS. 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