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APPLICATION FOR WELLIPUMP PERM: ~ SAN JOAQUIN COUNTY PUBLIC HEALTH SERPICES ENVIRONMENTAL HEALTH DIVISION P-0- BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (COMPlata in Triplicate) APPLICATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 19 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 ADDRESSOR APNn Road CITY Stockton PARCEL SIZE/APN* OWNER'S NAME Quik StopMarkets Inc. ADDRESS PO Box 5745, Fremont PHONE* 657-8500 CONTRACTOR_ Smith Technology Corporation ADDRESS 441 N Whitman Rd uc* PHONE 196i�_ SUBCONTRACTOR Exlzloration Geoservices Inc ADDRESS 1535 Injustr a Aveup,48J288. p TYPE OF WEL1/PUMP. El NEW WELL ❑ REPLACEMENT WELL 91 MONITORING WELL*-MW- 1 _2_2 & 3 ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL* (TYPE OF PUMP) ❑New❑Repair H.P. DEPTH PUMP BET FT. FIRST WATER LEVEL D Ips 13OUT-OF-SERVICEWELL ❑ GEOPHYSICAL WELL* 13 SOIL BORING ; g W DESTRUCTION:_Destroy Monitoring Hells MLI*-1 a2 A 3 by pressure gro 1 i nq INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 8 n DIA.OF CONDUCTOR CASINO N/A D ❑ DomEBTIC/PRIVATE ®GRAVEL PACK/SIZE 2112 sdndTYPE OF CASING/STEELmVC PVC DIA.OF WELL CASING 2" D ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL 40 O SPECIFICATION Sch. 40 R ❑ IRRIGATION/AO ❑OTHER GROUT SEAL INSTALLED BY ��Tryryremi a GROUT BRAND NAME y� E ® MONITORING GROUT SEAL PUMPED: ❑Yee ISL No CONCRETE PEDESTAL BY DRILLER:❑Yee INN. S / APPROX.DEPTH fp O LOCKING CHESTER BOXISTOVE PIPE S PROPOSED CONSTRUCTIONAMLLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL SE 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 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKIMAN'a COMPENSATION LAWS OF CALIFORNIA.' T MUS ALL 24 t DVANCE FOR ALL REQUIRED INSPECTIONS AT I2oaI 4ea0423. COMPLETE DRAWING AT LOWER AREA PROVIDED. elemd X Title Project SUpervi sor Date 1 f//y X 9(0 ROT PLAN*Drew to Seale)Seale 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. .. _ . - _ -.. i : -- See 'incltided Site P1 an _. .... :. . ....:......:... :... .:. . {{ I _ .. . C .. .' . ..... ..... . ... ......: _... .. :.. ....... . . . _.. .......... . . .... ... ... ..... . .... . L . .... .........:.... ............. ............'..... ..............'.. ,......:: DEPARTMENT USE ONLY Applleatlen Accepted By L Data C Area Grout Impaction By c Date Pump Impaction By Date Deetructlen Impaction By Date Comments: ACCOUNTING ONLY: AID* FAC* OZ PE CODES FEE INFO AMOUNT REMITTED CHECK*/CASH RECEIVED BY DATE PO MIT/SERVICE REQUEST NUMBER INVOICE 0�- 600.05 001 c 5