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p '1PPLICATION FOR WELL/PUMP PERMI" SAh"JAOUIN COUNTY PUBLIC HEALTH SEI",,,,,,..ES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (COMPbbtb In Tripiientel APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WTTII SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9.1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APNI49 South Wilson Way CITY Stockton PARCEL SIZE/APN#a roX. 0.7acres OWNER'S NAME Wells Fargo &mk ADDRESS 633 Folsom St. , 6th Fl. P ..��15) 396-3-077 CONTRACTOR Gregg Drilling ADDRESS `cam LIC, 485165 P.,,,,,,(925)313-5800 OUR CONTRACTOR ADDRESS LICK PHONE i TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# 11 J New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL RYPE OF PUMP) p �1 ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING 9 py DESTRUCTION: DY'l l I ()I If- tkp TTIMj tprl na WPl I C an j1YPlqsl lrp grA011t two m r,i tori we IS INTENDED USE TYPE OF WELL CONSTRUCTION bPECIFICATIONb A INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO p ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEEL/PVC DIA.OF WELL CASING p ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Ys [IN. CONCRETE PEDESTAL BY DRILLER:❑Yee [IN. S APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTION/DWLLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE 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:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 814ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS iS8VE0,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' =7A%L 24 8 IN ADVANCE FOq ALL REQUIRED INyb�►/E]CT10N8 AT f209148111-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. q SlOned X Tltls /I l C!Gt f�4�/�"1 if J��IrI/ /�,I r^C �//�C Data 7_G(p- PLOT PLAN(Draw to Seats)Seale 'to 1. NAMES OF BTRE S OR ROADS NEAREST TO OR 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 DISPOBAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED b. 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. 5 ✓� . f�Ti l !Cl l T PLA4d t '^( DEPARTMENT USE ONLY Application Amool.d BY N Y- i� - Date l Area Grout Incpoetlon BY Date_ Pump Inspection BY C� Date Deaom0an Inspection By- Data Comments: ACCOUNTING ONLY: AID# FAC! PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE PERMITIbERVICE REQUEST NUMBER INVOICE O �O Pub.Health Serv.-Enviro.173(1/97)