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e APPLICATION FOR WELLIPUMP PERMIT 41AN JOAUUIN COUNTY PUBLIC HEALTH SERVICE ENVIRONMENTAL HEALTH DIVISION P•0, BOX 3881304 EAST WEBER AVENUE, STOCKTON, CA 95201388 12091409-3420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICBmpIEIE In TripRente) APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOMR INSTALL THE WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WRIT BAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1115.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSIOn AAePIM UU In Road Ir( Stockton PARCEL SIZE/AMI c/ot onldr ras�iw a evine- r c e- econ mer T e 608-1829 OWNEn'B NAME T ADDDESS T PIONE910-652-4500 CONTRACTOR ADDMOB HCI PHONE A BuscoWRAcron Gregg��EDrilling & Testing ADDRESS 9aortdnez,R��d94553 ucf;A 485165 PIIONE�10-313-5800 TYPE OF WELLIPUMP: Atl NEW WELL ❑ REPLACEMENT WELL ® MONITORING WELL I ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROMI-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J HYPE OF PUMPI 11N.0 FP e lr H.P. DEPTH PUMP SET-FT. FIRST WATER LEVEL 0 ❑ OUT-OR SERVICE WELL ❑ GEOPHYSICAL WELL E ❑ SOIL BORING S ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑+1 OPEN BOTTOM DIA.OF WELL EXCAVATION 12-inch DIA.OF CONDUCTOR CASINO D ❑ DOMESTIC/PRIVATE DO GRAVEL PACK/SIZE TYPEOFCARINGISTEEVPVCPVC & Steel DHA.OF WELL CASINO 4-inch a ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROW SEAL45 feet SPECIFICATION cement- bentonite R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED�VBY driller BMW BRAND NAME E 0 MONITORING GROUT SEAL Pummm 13YN ❑NP CONCRETE PEDESTAL BY DRILLER:❑Y. ❑Ne S APPROX.DEPTN LOCKING CHESTER BOX/STOVE PPE S PROPOSED CONSTRUCTIONRNELLINU METHOD: MUD ROTARY AIR ROTARY XX AUGER CABLE OTHER I monitoring well I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WDW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY OWINANCER,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 MW FOR WHICH THIS PERMIT IS ISSUED.I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- COWRACTOWB HIRING OR OUR CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -1 CERTIFY THAT IN TIIE PERFORMANCE OF THE WOW(FOR WHICH THIS PERMIT 19 ISSUED,1 SMALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOURM IN PAMA 1]08145S�S!122P.. COMPLETED �i MPL E D 4 kT LOWERDAnEA-T� Z > V Till. PLOT MN 0.1.Sahel%.I. -le 1. NAMES OF STREETS OR ROADS NEAREST TO On BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED Z. OUTLINE OF THE PROPERTY.GIVING DIMENSIONS AND NOW"DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. S. DIMENSIONED OMLINF.S AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SVC"AB PATIOS,DRIVEWAYS.AND WAIXS. ON THE PROPERTY OR ADJOINING PROPERTY. ❑ �r LLJ Ju u Lincoln Road A-zone Pilot®�® G.4Q B-zone E10,o 21 LINCOLN N c� ELEMENTARY SCHOOL 0 O 0 ]0]Fffi 1 *SDCDs defined in the First Final Consent Decree Order ud�ement and Referenced to Special Master, filed with the Court on January 18, 1996, Section IV, Paragraph tDfIART ENr SE GnLY APPSesOen AceePleX By Deb q-15- -4- Are. OreM Impeallan BY ONa P P ImPeaGen BY Deb Omfrfsllen ImP Ilan By ny.�� Oefe G cemmerAe:�r LLGi�S�t1.fQf7lQ'Vl`I' �►1TLlR ��' Vy I.LVIC..O�VI �LfI.CA —+' ACCOUNTING ONLY: AIDS FACE PE CODES FEE INFO AMOUNT REMITTED CIIECKIICASH PIECBVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE Z�lo �� 1553 X1221 Pub.Health Sew.-Enviro.173(3/96)