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r APPLICATION FOR WELLIPUMP PERMIT -� �f SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICIs-'.10 ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388,446 N.SAN JOAQUIN ST,STOCNTON.CA 962oll -- (109)468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Momplflf in Triplieuo) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS AMICATIONIB'MA0EiN-69MPNANCE WITH S N JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOBADDRESS/ORAPN# 4520 S. Hwy 99 Frontage Road CITY Stockton PARCEL SIZE/APN# Yellow Freight System, Inc1099 Rhe A9 180U--458-3323OWNER'S NAME ADDRESS n V P Y Fi T1 Par r TCG PHONE Woodward-Clyde 10370 Old_Placerville RD 916-368-0988 CONTRACTOR ADDRESS_ ! PHONE• `�""'` — 209-465-8712 SUBCONTRACTOR Spectrum Exploration ADDRESS 2825 ! M rtle uc,512268 PHONE# oc c on, TYPE OF WELUPUMP: ❑NEW WELL ❑REPLACEMENT WELL ❑MONITORING WELL# ❑OTHER ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# ✓ ❑New❑A-M, H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O ITYPE OF PUMP) 2 to 3 ❑OUT-OF-SERVICE WELL ❑GEOPHYSICAL WELL# `MU'X"SOIL BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING O ❑DOMESTICIPRIVATE ❑GRAVEL PACK/BIZE TYPE OF CASING/STEEUPVC DIA.OF WELL CABING O ❑PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL 7 0 t SPECIFICATION R ❑IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E lZiAoNITORING GROUT SEAL PUMPED:❑YM ❑Ne CONCRETE PEDESTAL BY DRILLER:❑Y.. ❑N. S APPROX.DEPTH 7 0 1 LOCKING CHESTER BOXISTOVE PIPE S PROPOSED CONSTRUCTIONAMLLINO METHOD: MUD ROTARY AIR ROTARY AUGER X CABLE OTHER I HEREBY 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,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.'CONTRACTOR'S HIRINO OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: ,I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT I6 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE A►PUCnPITT MM�U,ST C�24�URRSS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12051 4SSJ422.COMPLETE DRAWING AT LOWER AREA PROVIDED. SlVrweX N-7 -('�1'L'2-- L� TN% Geologist Det. 10/20/94 Bill Loskutof - PLOT PUN ID,.,,.,Ie B.M.I fiw. ,, T n, 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 Figure 1 1 DEPARTMENT USE ONLY Q ),w Appli-O.n A~.d BY D.I. �O��I— 14 A. Grout Irrpeetltm I D.te Pump IMPMOM By D.t. De ration Imp..ti.n BY D.t. Cemmentr. ACCOUNTINQ ONLY: AID# FAC, -CODES FEE INFO AMOUNT REMITTED NECK# fH RE VED SY DATE PERMIT/SBINCE REQUEST NUMBBt INVOICE 55m A91 PA,cv -Z!-94 6045V T