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APPLICATION FOR WELL/PUMP PE JOAQUIN COUNTY PUBLIC HEALTH WVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 4683420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED IComplets In Triolkm) APPLICATION IS HEAP BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OB INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH BAN JOAUUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAOVIN COUNTY MBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH OMB N. �A( fIfx �vC.�'r . JOB ADOREetrofl AMS CITY Stockton EL 2E/A I - Settling Dry Cleaning Defendents SDCDs 1 owe .� oor OWNER'SNAMEo.(n "1d T R -d hnc, ToVino-Rrir4e-Rerun ADDRESS Rmprymil ley CA 94608-1821 PHONE/ com RACTOR ADDRESS HCI MONE S 950 Howe Rd. (5iO)313-5800 SUBCONTRACTOR Gregg In-Situ Inc. ADDRESS Martinez AA 94�_ucFCA-656407 Mows TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL S ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROrs CONNECT REPAIR ❑ VAPOR EXTRACTION WELL S ✓ ❑N.13 R .I' N.P. DEPTH NMP SET—FT. FIRST WATER LEVEL O RYPE OF MMPI ❑ OUT OR6ERVICE WELL ❑ GEOPHYSICAL WELLS ® 601E BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 9-inches DIA.OF CONDUCTOR CASINO N/A D ❑ OOMESTICNmVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/FVC N/A DIA.OF WELL CASINO N/A 0 ❑ PURUCMUNICIPAL ❑OnIVEN DEPTH OF GROW SEAL Total Depth SPECIFICATION Cement-Bentonite A ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY Contractor Grow BRAND NAME N/A E ❑ MONITORING GROUT SEAL PUMPED: ®Y. 11 N- CONCRETE PEDESTAL BY GRILLER:❑Y. CIN. S APPRO%.DEPTH BO feet LOCKING CHESTER BO%/STOVE RPE N/A S PROMSED CONSTRUCTIONRSBLUNQ METHOD: MUD ROTARY AIR WTARV AUGER CABLE OTHER Hydraulic Push 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES ANO REGULATION9 OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE wow FOR WHICH THIS PERMIT IB ISSUED,I$HALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUR CONTRACTING SIGNATURE CERTIFIES THE FOLLOW W0: I C RTIFY THAT IN TIIE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IB ISSUED,I$HALL EMPLOY PERSONS SUBJECT TO WORXMAMS COMPENSATION LAWS OF CALIFORNIA.' THEA CANT MUST CA 34 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 120S14Y-1422. COMPLETE DRAWING AT LOWER APPA mc)"7 IOC./ ,,P.4% .�� -_7Sl TRI. S?a Prnj PVY Manager D.I• ! `7 PLOT PLAN ID—1.%W.1 B.Ne •to I. NAMES OF 9TPEE18 OR ROADS NEAREST TO On BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On 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 R. STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. E z� 1 I_...1_....: t : , Ir FV r 1 '1...� �........'m�.. .......... c <I..� 1 1 —.....� $ t, J �` —I I -�•1U��'�-1 '. °pl' / . _i �1"- ,�a �4eaAa•�""<y �� a� �� °�@$ cgvs To'Ic j DEPMTMMT IME ONLY AFpg"Om A.B W BYOSIS i•4�• / / Aru OF"ll. dwI BY Li D.R. PVmp Imo••Uen By Dae DeN.Wbn In/.IN�a�Ria�n� ��''"" '' O C..I..RN.:�'f- JfDC.k'rD/) LyE.c..t'04t�'Lf'Y�^`r �l VYll7 Eo� �2�0 �f7 10•t' ! '2L ACCOUNTING ONLY: AIDS FACS PE CODES FEE INFO AMOUNT REMITTED CHECKSICASH RECEIVED BY DATE I' MITISFNVICE REQUEST NUMBER INVOICE B 61 as 05- R.i . o�3(v-- z Pub,Health Serv.-Enviro.173(1/97)