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APPLICATION FOR WELLlPUMP PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON,CA 95202 (209)468-3420 I7�✓ 8CT N'1°N JIV R•R FQRDABLE PENSIr ExF]AES 1 YEAR FROM DATE ISSUED (GDIpIStB IN TrpRNNRSI j APPLICATION R MIRE BY MADE TO THE BAN JOA"COUNTY FOR A PERMIT TO CONSTRUCT AINDAR INSTALL THE WORK DESCRIBED.TI IB APPLICATION IS MADE IN COMPLIANCE WRIT SAN JOAOUN COUNTY DEVELOPMENT TRIS,CHAPTER 8.1 T 15.3 AND THE STANDARDS OF BAN JOAOIIJN1CQ�INTY PUBIC HEALTH BEIMCEB,ENVIRONMENTAL HEALTH OMSION, JOB AODRESSMm NNS. BETHANY RD. ',t4 Ml . E. OF B Y R 0 N c fir,,-V jj�T TRACY PARCEL RIZVAPNF ommirms NAME EVERETT RANK NS ADDRESS 16850 TRACY BLVD. TRACY PHONE. 836-1638 CONTRACTOR HENNINGS BROS. DRILLING CO. INC. ADDRESS 3525 FELANDALE MOD ucs 290813 PHONE, 545-1185-- BUD 45-1185 —BUD CONTRACTOR ADDRESS UC, PHONE! V TYPE OF WELLAUMP. 91 NEw WELL ❑RM-ACEMENF WELL Q MONDORNG WELL. ❑OTHER yJ ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑cR]BR.cbNNECT REPAIR ❑VAPOR EXTRACTION WELL IF J lJ 11N-L7 F. N.P. DEPTH PUMP SET FT. PRIF WATER LEVEL p J fFYPE Of PUMPI .--I 1 ❑Oth-0E-SERVICE WELL LJ GEOPHYSICAL WEU/ ❑ San BOEING •`,} ❑OESTRl1CT ROH: � INT Om W TYlI OF Wq& CONSTRUC ION 5PECIRCA710NB Jq ❑INOUBTTNAL 0OPEN RoTTDM ORA.OF WELL EXCAVATION 1211 11 WA.OF CONDUCTOR CABINU 1� ^ n OOMESTICTNVATE JRGRAVEL PACKMZE TYPE OF CASWGIVIEELTVC PVC DIA,OF WELL CASING 611 O ❑PUSUC)MUNICEAL ❑bRVPf DEPTH OF GROUT REAL 1 0 0 1 SFECFRCATION BENTONITE A _ ❑IRSGATIONIAO ❑OTHER GROUT SEAL INSTALLEDBNBTy H E N�!I N GS GROUT BRAND NAME .�, E� 13 MONITORING 200' GROUT REAL P)MPEO:UI Y.. ❑FI. COFKCRETE PEDESTAL sYbRLIER❑Y- 4lyrJ Ne 3 API'RON.OF1TN LOCKING CHESTER BOXWOVE PALE .E P OPOSM CONBTRUCTIONCRILLNO METHOD: MUD NOTARY X X AIR ROTARY AUGER CABLE OTHER .ti 1 HEEIY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AMC THAT TIE WORK WILL BE DOME N ACCORDANCE WITH BAN JOAGUN COUNTY INDINANCE9,STATE LAWS.AND RULES O ANf ,h REOURATIONS OF THE BAN JOAGUII COUNTY,HOME OWNER ON UCENUO AGENT'S SIGNATURE CENTIMES THE FOLLOWING:'1 CERTIFY M THAT W THE PERFORMANCE OFTIE WORK PORI WHICH V S THIS PE18MT N ISSUED,I BIIALL NOT EMPLOY PFRNONN SUBJECT TO WORKMANY COMPOMATMN LAWS OF CALIFORNIA.- CONTRACTOR'S HGONG OR OUB-CONTAACTNO SIGNATURE CE/RFEB- THE FOLLOYMM! '1 CERTIFY THAT N TIE PPVVMANCE OF THE WORK FOR WHICH THIS PERMIT IB 1BSUED,I SHALL EMPLOY PERSONS SUBJECT TO WOIOMM'S COIMPI NOATION LAWN OF BCS OOFORA.Q TIMI AI PUCAN�MUST�ST CAU24HOURS IN ADVARC FOR A PAOMED INSGP%Cm N TCznf 4*94E22.CVMgFTE DRA~AT LOWER AREA PFlOVIDEO. s cL S �e-vt June 9, 1998 K PLOT MN A.v R.9..IM ft.. t. 1.NAMEB Of STREETS OR ROADS NEAREST TO OR BOUNOTHE PROPERTY. A_LOCATPON Of HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED I.OUTLINE OFNB PROPERTY,INCTHE PPERTY,aNNO DIMENSIONS AND NORTH DIRECTION, EXPANSION OF BEWAOE DRBP09AL IYSTLAFS. S.DIMENDONED OUTUNF9 AND LOCATION OF ALL EIDSTNO AND PNDPGSEO S_LOCATION Of WELLS WITH/l RADIUS OF ONE HUNDRED FFTY FT. STRUCTIHES,NCLUDNO ETE COVO AfEAB OUCH AS PATIOS,DRIVEWAYS,AND WALKS, ON THE PROPERW OR ADJOINING PROPERTY. I-_ R.bA . - _ PAYMEN17 REGE vEr �jk1 1998 I SAN JpAUUIN C rdUNT'f PUSUC HEALTH SERVIrcc .1 ENVIRONMEN?ALHF-AUrF- '.3!'�N DEFAAMENT USI ONLY AF►S..Ih-AO-1.O LIP D... MNaul 1r,IP.eRRw./r 111 X-t' PL NM-tf-eY b...wNPn•'.R..PRI...B b.R. C± c.,..., l IQ 3A iC i_ fC'Iki1 - ''f Fo}t .,YL-�' TC&�7 ( ':� -',K !'?4� _ 2-98 ACCOUNRNG vMY; AID! FAC. PE CODES FEE INFO AMOUNT REMITTID EE )CASH RECEIVED IV DATE P'10.11TNNNICE REOUEST NUMBYI NVOICE