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APPLICATION FOR WELLIPUMP PERMIT AN JOADUIN COUNTY PUBLIC HEALTH SERVIL ENVIROF AL HEALTH DIVISION P 0 BOX 388,445 N.SA. ADUIN ST.,STOCKTON,CA 95201.388 I209I 488.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICA71ON IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN# 14700 W. Schulte Rd CITY Tracy PARCEL SIZE/APN# OWNER'S NAME OWeTIC Brockway Glass ADDRESS R-q RIP PHONE+SA6—RSG CONTRACTOR C.]a rk Wel I t)_71 C ADORE66 2024 F C h a r 2 F uc#3 7 1 560 fMiONE#li Fi 7—7 N 7 F1 SUB CONTRACTOR ��77 ADDRESS LIC# PHONE# TYPE OF WELUPUMP: ❑NEW WELL ❑REPLACEMENT WELL 4 A-X MONITORING WELL# ❑OTHER ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# ✓ ❑New❑R-1, H.P. DEPTH PUMP SET ..... FIRST WATER LEVEL 0 (TYPE OF PUMP( ❑OUT-OF-SERVICE WELL ❑GEOPHYSICAL WELL I ❑ 601E BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑INDUSTRIALJ❑OPEN BOTTOM �l�J SIDIA.OF WELL EXCAVATION '1 O 11 DIA.OF CONDUCTOR CASING N n D P [3 D ❑DOMESTIC/PRIVATE XGRAVEL PACK/SIZE •'l1 TYPE OF CANG1.TEEL1PVC PVC DIA.OF WELL CASING C r}T A n ❑PUBLICIAUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL a r 0 X 1 S n SPECIFICATION G VER y❑IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED �BTY� C,1 a r It GROUT BRAND N E ♦!.MONITORING GROUT SEAL PIMPED:O&W. 13 N. CONCPETEPEDEST Y/DMLLEFK[OY- ON. S APPROX.DEPTH 1 Rn 1 LOCKING CHESTER BO/STOVE RPE PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY X X AIR ROTARY AUG CABLE OTHER I ryw[5 70 Ptr-ecj' I HE9EBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAGVIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAOUINT COUY. E OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED' I SHALL N E OY PERSO �`SLEN BJE T TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.-CONTRACTOR'S HIRING OR SUBCONTRACTING SONATUF E CERTIFIES THE FOLLOWING: 1 CE'''ppp///}}}11AI T HE RFO AN E F THE W.I.FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANTET LL 0 E FOR ALL.REOURED INSPECTION$AT 12091 444,2423.COMPLETE DRAWING AT LOWER AREA PROVIDED. filenedx / Tld. VP Clark Well. 13-31 Mar 95 rPUN IDlew to Sul.)Sula 'to 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. 'V! I DEPARTMENT USE ONLY APPneeion Aeeeetod By / / / /`�- D— y 3•�5 A— g9 D I Grout Img—flon By Det. P—P In.Peenen By Det. D—uctlen Imp-tion BY Det. Comm-4: ACCOUNTING ONLY: AID# FAC/ PE CODER I FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE t 2510 23g7— 4.3 (fib5�