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`PPLICATION FOR WELLIPUMP PERMIT f SA.. .OAaUIN COUNTY PUBLIC HEALTH SERVICES ' ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCXTON, CA 95201388 JUN Z 11995 {203) 488 3420 NON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH (Complete 1t Tr*licagl PERMITISERVICES APPLICATION 18 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 WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE CHAPTER 9-1115 3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVZ940N JOB ADDREBBAOR APNrL72701 N. W3.1son Way crry StOCktonc CA 95205 PARCEL scwAPNI OWNERS NAME_U—HAUL gaoginy of Fresno ADORIESS749 N.Blackstone Ave, F resnOPHo.E#(209) 487-1723 CONTRACTORSciectrum EXpI_oratlon, inc. ADDREse 236551�WZC1wam Way uc# S12268 PHONE 4 209) 465-8712 SUBCONTRACTOR_. N!A —. ---- --- SSStockton, CA 95205 uc# PHONE TYPE O,F WEUJPUMP ® NEW WELL ❑ REPLACEMENT WELL ❑ MONrTOR1NG WELL#MW—S ❑ OTHEA ( -3 ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J ' 13 New 13ReOefr HIP DEPTH PUMP SET FT FIRST WATER LEVEL O 1. , (TYPE OF PUMP} ❑ OUT-OF-SERVICE WELL ❑ GEORNNYSNCAL WELL I ❑ SOIL BORING B ❑DESTRUCTION INTENDED USA TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL 13 OPEN BOTTOM DIA OF WELL EXCAVATION_ _8if DIA.OF CONDUCTOR CASING N/A a ❑ DOMESTICIPR IVATE ❑GRAVEL PACKtau No., 2 TYPE OF CASING/STEEUPVC. _ , C DIA.OF WELL CASINO 4" O , ❑ PUBM MUINICIPAL ❑DRIVEN Monterey DEPTH OF GROUT SEAL riR' SPECIFICATION Sf'�'Te6 i l L 40 R ❑ IMWATIONAAG 0 OTHER Sand GROUT SEAL INSTALLED BBY,DIM= GROUT BRAND NAME VOZClay E ® MONITORING GROUT SEALL PUMPED U YM M. CONCRETE PEDESTAL BY DRILLFNL a, Yr [IN. S APPRvx 01FPTN 95 BGS _ -_ LOCKING CHESTER BoxASTOvE PIFEfZrf= BOX $ PROPOSED COKSTRUCTIONIDf6µdNQ METHOD MUD ROTARY AIR ROTARY X AUGER CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE 1MTN SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY HOME OWNER OR UCE46M AGENT 9 SIGNATURE COMMES THE FOLLOWING I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH , THIS PERMIT IS ISSUED I SHALL NOT EMPLOY PERSONS SUBJECT TO WORIKMAN i COMPENSATION LAWS OF CAUFORNIA. CONTRACTOR'.HmINO OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLI CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED I SHALL EMEN. PLOY PERSONS SUBJECT TO WORKMAN 8 COMPATION LAWS OF CAUFO M' APPLICANT MINT CAU.M RJRi ADYANf.E FOR ALL REQWIED INSPECTIONS AT(20101469-3423 COMPLETE DRAWING AT LOWER AREA PROVIDE (� � Signed X Title JOF PLOT PLAN(Draw to Scow Seel* 'n I NAMES OF STREETS OR ROADS N ST TO OR BOUNDLNO THE PROPERTY 4 LOCATION OF HOUSE SEWAGE DISPOSAL,SYSrEIM OR PROPOSED 2 OUTIJNE OF THE PROPERTY GIVING DIMENSIONS AND NORTH DIRECTION EXPANSION OF SEWAGE DISPOSAL SYSTEMS, 7 DIMENSIONED OUTLINES AND LOCATION OF ALL EXISITNG AND PROPOSED 6 LOCATION OF WELLS WITHIN RAMS OF OHF HUNDRED FIFTY FT STRUCTURES INCLUDING COVERED AREAS SUCH AS PATIOS DRIVEWAYS AND WALKS ON THE PROPERTY OR ADJOINING PROPERTY t ADE?ARTMENT UaE vxLY pplaetbn Accepted BY Grout Inspection BY Date Ptenp Inspection BY Date�e ' Destruction InPectlan BY 4 Dew Comments (Za 7 ' ACCOUNTING ONLY AID# FAC# PIE CODES Fu INFO AMOUNT REMITTFb CNWX.NCASN RECEIVED MY DATE P9pMIT/SERV1C1 REQUEST NLIIMtW INVOICE l 3 -Z/5 0 5 cuo