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APPLICATION FOR WELLIPUMP PERMIT SA )AKIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION JUN Z 1 1995 P 0 BOX 388, 4411 N. SAN JOAOUIN ST, STOCXTON, CA 96201 39B (209) 488 3420 ENVIRONMENTAL HE ALTH NONREFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED PERMITISERVICES ' lCamplats N Trglieats) APPLICATION IS HERE SY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED THIS APPUCATFON 18 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1 115 3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION JOS AOORESS/OR AP%# 2701 N Wz n Way cm. Stockton CA 95205 PARCEL sI2E/APNF OWNERS NAME U-Haul gaMAM of Fresno ADORESs749 [V Blackstone Ave Fresno PHONE 4 209) 487-1723 CONTRACTOR Spectxzun �mlorat�on, Inc. ADDRESS 2365 W3-gRam Way ucs 512268 PHONE 4 209) 465-8712 suis cows ACTOR „.Stockton, CA 95205 LIC O PHONE I ' TYPE OFt%6Wn1MP• 0 NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING F-—MW--2 9 OTHER ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSS-CONNECT AIR VAPOR EXTRACTION WELL s ,! N ' ❑New Cl Alwow H.P DEPTH PUMP SET FIRST WATER LEVEL O (TYPE OF PV MPI ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL IF ❑ SOIL SORING a Cl DESTRUCTION INTENDED UIS TYPE OF WELL CONSTRUCTION 6PEC1F4CATTONi' p A C3INDUSTRIAL 13OPEN BOTTOM �7 DIA OF WELL EXCAVATION OI' OUL OF camucTOR CASINO N/A D 13DOMEgmmmVATE ❑GRAVEL PAousm`**��^+. 2 TYPE OF CASINO) MMIPVC PVC DIA.OF WELL CASING 411 a ❑ PUBLIC/MuNIcIPAL ❑DMVM Monterey DEvm OF GROUT sm......9B: SPEc1PLCATLON _,achedule 40 R r— ' ❑ IRRIOATTON/AO 13 OTHER S^,,,,� Cu ul GROUT SEAL INSTALLED BY Pimp .�'�T1T^7�r GROUT BRAND NAMEIII] _ ]C_ a�z E T� D MONITORING GROUT SEAL PUMPED P Yr ❑Ne CONCRETE PEDESTAL BY DRILLFR.fR Yr ONO S 7 APPROX.DEPTH 95' BGS LOCKING CHESTER BOIufTOVE PIPE ly 1r $per s V ' PROPOSED CO04aTRUC7IONIDWLUN0 METHOD MUD ROTARY AIR ROTARY X__AUGER CABLE OTHER I HEREBY CERTIFY THAT 1 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 7 CERTIFY TNAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED I SHALL NOT EMPLOY PERSONS SUBJECT To WORKMAN f COMPENfATION LAWS OF CALIFORNIA. CONTRACTOR S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FO 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WINCH THIS PEIIMIT IS ISSUED I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN Y COMPEISATION LAWS OF CAU A.';TH5,7ANT MUST C No N E FOR ALL RECLMtM INSPECT1OMX AT(2001 4Y�2? COMPLETE DRAWING AT LOWER AREA PROVIDED 10819nold X TIUs -- ... Dater-` PLOT PIAN IOraw ca So"SSW 'to ' 1 NAMES OF STREETS OR ROADS N O OR SOUNDING THE PROPERTY t 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 OUSTING AND PROPOSED 5 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 �1 N ' 0 N DEPARTMENT UIM ONLY' ,6/�►.��Osco 1 f�^-� Ar AppNwtYon Aeogtsd By Graa Irrpoodon av Dace P—p Irrpaaclon BY oats Owvmallon Irrpmc4en By g Oms Comm.,c. Jf7� u ' ACCOUNTING ONLY AIDP FAC# PE CODES FEE[NFO AMOWIT RE WWED HEC !CASH RW8VED Y DATE PW MT"nMCE REOUEBT NUMSER INVOICE a-/ 1