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r <br /> I APPLICATION FOR WELIJPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 L <br /> NOR REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (CbmplSt/he TTIpRnt:! <br /> APPLICATION 19 HERE BY MADE TO THE SAH JOAOUI1 COUNTY FOR A PEFMAIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED THIS APPLICATION 18 MADE IN COMPLIANCE WTTFI SAN <br /> JO ADUIN COUNTY DEVELOPMENT TfTLE CHAPTER 9 1 1 1 S 3 AND THE STANDARDS OF BIW JOAOUIN COUNTY PUBLIC HEALTH SERVICES EWPONMENTAL HEALTH DIVISION <br /> 4 .78 acre <br /> JOSAODRESSIORAPN/ 2427 West Yosemite Avenue CITY Manteca PARCELSIZVAP"P 19817006 <br /> I owwPSN^me ABF Freight System, ADDRESS om+( 5Q1 ) 7858 01 <br /> CONTRACTOR C wowIE6S2040 PeabodK Rd _� 5775�w+v►+E(�707 4479 <br /> 9U9CONT1RACTORBa ADDRESS Vacaville CA ur-#522125 PHONEa00 622DR1 <br /> I ��....� 593 central <br /> TYPE OF WELLMUMP; ❑ NEw Yam ❑ FEPLACEMENT WELL [$MowroRING WELL 0 3 ❑ OTHER <br /> ❑ FNSYALIJLTION ❑ WELL SYSTEM REPAIR ❑ CND/S{ONHECT REPAIR ❑ VAPOR EXTRACTION WELL/ J <br /> I ❑N.13 .P <br /> P +Ir HIP DEFT"PUMP SET FT FIRST WATER LEVEL O <br /> (TYPE OF pUMPI <br /> ,,++}� <br /> ❑ OUT-OF-8EREVICWELL ❑ GEOPHYSICAL WELL/ ❑ EOR.SORING B <br /> C9oESTRUCTIONProposed: pressure grout seal 7-nq Qf I man j t a r i n a„ FJa7 7 S MW-.1_� -� �. —3 . <br /> I INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DFA.OF WELL EXCAVATION DIA OF CONDUCTOR CASINO D <br /> I <br /> ❑ ODMESTIGPRIVATE ❑ORAVEL PACVMZE TYPE OF CASING/STEELRVC DIA OF WELL CASINO 0 <br /> I ❑ PUIUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION A <br /> ❑ /VVOATION/AO ❑OTHER GROUT SEAL INSTALLED BY GTIOUT BRAND NAME E <br /> ❑ MONITORING GROUT SEAL PUMPED' ❑Y+• ❑N• CONCRETE PEDESTAL BY DRILLER ❑Yet ❑Ne S � <br /> APPROX 017114 LommN CHESTER BOXffrOVE PIPE S <br /> wOP016D CONSTRUCTIORUONLLINO METHOD MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> Jee atta hed Monitorl.ner,P71 3_c( � fnr r7ataT 1 a of wel 7___cnnctrTTrf on <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED TMS APFPU ATION AND THAT THE WOfiC WILL SE DONE IN ACCORDANCE WITH/AN JOAOVIN COUNT`/ORDINANCES STATE LAWS AND RULES AND <br /> REGULATIONS OF THE SAN JOAOURI COUNTY ROME OWNER OR LK:EHBED AGENT b SIGNATURE CtKrIFIE/THE FOLLOWING I CERTIFY THAT IN THE PEWORAANCE OF THE WORK FOR WHICH <br /> I <br /> THIS PERMIT 16 ISSUED I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN i COMPENSATION LAWS OF CALIFORNIA. CONTRACTOR S HI 140 OR SUB CONTRACTI M SIGNATURE CERTIFIES <br /> THE FOLLOWING 'I CERTIFY THAT IN THE PERFORMANCE OF THE W AK FOR WHICH TMS PEIO+UT 18 ISSUED I SHALL EMPLOY PERSONS SUBJECT TO WORIMAAN S COMPERSATION LAWS OF <br /> CALIFORNIA' THE APP'UCANT MUST CALL 24 HOURS IN ADVANcE FOR ALL REOUMED INSPFCTIONII AT 120/1 4418-b422 COMPLETE DRAWING AT LOWER AREA FRONDED <br /> elo...e x <br /> 1 Tltm -V A, A/IGCZ-*4 [ D•t. <br /> PLOT PLAN(p.�r to/••1y ea.t•�j] t•�„�,t <br /> 1 NAME/OF STREETS OR ROADS NEAREST TO OR BCVMWM THE PROPERTY S LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2 DTEINE OF THE PROPERTY IVN <br /> RTY OG DIMENSION/AND NORTH p11ECTION EXPANSION OF SEWAGE DISPOSAL/Y/TEM/ <br /> U <br /> DIHTENMONED OUTUNF/AND LOCATION OF ALL EXWrINO AND PROPOSED i LOCATION OF WELLS WTi'I#N RAdU/OF DHE HUNDRED FIFTY FT <br /> STRUCTURES INCLUDING COVERED AREAS SUCH AS PATIOS DRIVEWAYS AND WAIT/ ON THE PROPERTY OR ADJOtH M PROPERTY <br /> Please see attached plan map. <br /> I <br /> �1 <br /> IDEPARTMENT USE ONLY <br /> APplla•Ilen Ano+al•d BY Date Mr <br /> AvaR ile.Aro ar Date P,.m 1n+•+etl•n by 7_ Owe— <br /> J X <br /> ."LA) D•I•� � — <br /> C•.wmsw+ <br /> Fr- <br /> I <br /> ACCOUNTING ONLY AIDS FACS <br /> PE CODES FEE INFO AMOUNT RE MITTED CHECE91CASH RECEIVED/Y DAT FSPINAII/ERVICE REQUEST NI1MS@I INVOICE <br /> So o. Da 3Z f i O 1,5LS <br /> -oath 4ary ;�^Vlfo <br />