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APPLICATION FOR WELL/PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICempleff ie Tripliestal APPLICATION IS HERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER B-1115.3 AND TILE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC 14FALT14 SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN# 814 E. Charter Way gym, Stockton 167-181-01 PARCEL 612ElAPN# OWNER'S NAME Morita Brosthers ADDRESS 6622 Belmont Pl. Stockton PHONE# 478-7546 CONTRACTOR V&W Drilling P.O. Box 51 ADDRESS Rio Vista, CA LI,720904 R„ONE,707 374-2815 PUB CONTRACTOR ADDRESS LICI pp�, PHONE /PU TYPE OF WELLMP' 14 NEW WELL ❑ REPLACEMENT WELL ESI MONITORING WELL# 4 ❑ OTHER ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J RIPE OF PUMP) N.❑R.p.lr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ BOIL BORING S ❑DESTRUCTION: INTENOED USE TYPE OF WELL CONSTRUCTION tPECIFICATIONS 1 A ❑ INDUSTRIAL 5 OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO 211 D ❑ DOMEBTK:/PRIVATE 90RAVEL PACK/SIZE TYPE OF CASINO/STEELJPVC PVC OIA.OF WELL CASINO 211 ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL 23' SPECIFICATION net Cement R ❑ MRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY V&W GROUr BRAND NAME E EI MONITORING GROUT SEAL PUMPED:R1Yw ❑Ne CONCRETE PEDESTAL SY DRILLER: Y« [IN. S APR10 X.DEPTH LOCKING CHESTER BOX/STOVE PIPE Box S PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER X CABLE OTHER I HMBY 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:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,1 SHALL NOT EMPLOY PE NO SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUS-CONTRACTINO SIGNATURE CERTIFIES THE FOLLOWING: •1 CERTIFY THAT IN THE P RMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA APPLICANT T CALL,Y4 ?XIII IN ADVANCE FOR ALL REQUIRED INS/Q/qTIIO�NSAT12001 4004422. COMPLETE DRAWING AT LOWER AREA PROVIDED. �J lrSnsd X TIN. i PLOT PLAN IDrow to Bc.lel Sod. •to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIV*M DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 2. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. 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. DEPARTMENT USE ONLY �7' Application Aea.pted BY (�i,��/�.at-� .' )1 Dote ��`� Ar.. n 7 }O 1/7 GIOut IMP-11en By l '�,�i1.� y�Zi D.to ' q j P� p Inrpeotlen BY DN. Dostrm len Impaction By -7 ,,^ /� ,j� Dd. ,! C.m 'A$: jtI /k._ Liv !�/LCit-�1 V�L oze t•....�.I GLi1..�:/ L?>/- vr.-L-Jt��1 ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE n.,,. i....u..c...., rn..i.n 1In 14107%