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r � �►ar � APPLICATION FOR WELLJPUMP PERMIT s=_w SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION '304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED IC9mpbte IB TTIplfenfel APPLICATION 19 HERE hY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 19 MADE IN COMPLIANCE WITH SAN JOAQUIN COUHj;EVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APN, 826 E. Charter Way NEj}%'IygCt.".�CITY Stockton PARCEL BIZE1APN0 167-181-02 OWR'S NAME Frank Kozlik 1iV�` At>OFIE99 P.O.Box 255708, Sacramento PHO/JE, CONTRACTOR V & W Drilling P. O. Bpx 51 ADDRESS Rio Vista, CA �c, 720904 PNONE,707 374-2815 SUB CONTRACTORyy ADDRESS LIC, PHONE, �1� TYPE OF WELL/PUMP: 1X NEW WELL ❑ REPLACEMENT WELL La MONITORING WELL, 5 ❑ OTHER ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL, J ❑New❑Rapelr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMP) ❑ OUT-OF-BERVICE WELL ❑ GEOPHYSICAL WELL, ❑ BOIL BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 8 1 DIA.OF CONDUCTOR CASING 211 O ❑ DOMESTIC/MVATE 12 GRAVEL PACK/SIZE TYPE OF CASINO/STEEL/PVC PVC DIA.OF WELL CASING 211 O ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT BEAL 2-1 1 SPECIFICATION neat Cement R ❑ IRRIGATION/AO ❑OTHER GROUT SEAL IN9TAII ED BY V & W GROUT BRAND NAME E IV MONITORING OROUT BEAL PUMPED: [3 Y. [IN. CONCRETE PEDESTAL BY DRILLER:®Yee CIN. S APPROX.DEPTH LOCKING CHESTER BOXISTOVE PPE S PROPOSED CONSTRUCTION/DRILUNIQ METHOD: MUD ROTARY AIR ROTARY AUGER X CABLE OTHER I HMNY 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 JOAOUM COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PEWORMANCE OF THE WORK FOR WHICH THIS PERMIT 16 ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORIHIA.- CONTRACTOR'S HIRING OR BUBCONTRACTINO SIGNATURE CERTIFIES THE FOLLOWING: -1 CERTIFY THAT 111 TL PERFORMANCE OF THE WORK FOR WHICH TH18 PERMIT IS 18SUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- HE APPLICANT.VST C 2�HOURS IN ADVANCE FOR ALL REQUIRED INS' fCT10NS AT 1205)Iq.f421. COMPLETE DRAWING AT LOWER AREA PROVIDED. Signed X -� TIN. �,CJW��Det. PLOT PLAN(Dr.w to 9oelsl Seal. 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING 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 EXISTING AND PROPOSED I. 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. (see attached) Q� 1 5 o / ✓7 DEPARTMENT USE ONLY Application Accepted BY t--�c"�li2�C '- c�`1/ ) Date 3—3 --c Are. Otout Impaction BY (`l�S /,�� Dote (/ Pump Inspection BY Data Oesum len Impaction BY Dote �+ j CommerNo: zj an n[moi .lt/l Q�CyY+t.GT �'�'�P G�.K.!/.[7 Q-e�ti..�..iJ /tt5 V /r(n ��il)%K X72 �it�G4'i'✓I 6�FSS�/ C.-�Ct.�-1w L✓�K ACCOUNTING ONLY: AID/ FAC, PE CODES FEE INFO- AMOUNT REMITTED C CK, ASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NLIMBERi INVOICE 52� 17 0 1 v `r