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APPLICATION FOR WELLIPUMP PERMIT issSAN JOAOUIN COUNTY PUBLIC HEALTH SERI,, r ENVIRONMENTAL HEALTH DIVISION N P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON. CA 95201.988 1 (209) 468.3420 NOP-REFUNDABLE PERMIT EXPIRES 1 YEAR FROU DATE ISSUED (Complete In Triplicate) APPLICATION IS 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 STANDAPDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APN* 7474 W_ 11th .�'t rPP t, CITY Tracy PARCELSIZF/APN* 250-200-01 OWNER'S NAME Frank Coelho ADDREss7474 W. 11th St. ,Tracy M311ZH Elg35-2421 94571 - t CONTRACTOR V R W Drilling ADDRESSPO Box 51 ,RioViSb&* 6587867UNEa 74-281 5 SUBCONTRACTOR �-I ADDRESS LIC* PHONE/ TYPE OF WELL/PUMP: y 1 NEW WELL ❑ REPLACEMENT WELL MONITORING WELL* 4—8 . 10 1 ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL* RYPE OF PUMP( 13Now 11Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL D �— ❑,OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL* ❑ SOIL BORING g ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS TT��ppppTT�� 77QQ,, (�� A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION_s- not Dl/k'.OF`CONDl1CTOR SING"ly 1 711 D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEELIPVC_S ch 40 PVC DIA.OF WELL CASING 7 _ C)" D ❑ PUBLIC/MUNICIPAL LL❑�TT DRIVEN DEPTH OF GROUT SEAL 5 1 g It 1 w/16 1 fl e e SPECIFICATION R ❑ IRRIGATION/AG pry OTHER GROUT SEAL INSTALLEDBYV R, W GROUT BRAND NAMENP.d Cement— E 9 MONITORING GROUT SEAL PUMPED: ry(Yaa [IN. CONCRETE PEDESTAL BY DRILLER:❑Yea ON, S APPROX.DEPTH To hp- determined 1n field. LOCKING CHESTER BOX/STOVE PIPE X—traff lc rated box S PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER X CABLE OTHER I HEREBY CERTIFY THAT I 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 IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLO G I CERTIFY THAT It THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN-S COMPENSATION LAWS OF CAUFORNI CANT IIUSX CALIF24 HOURS IN ADVANCE FOR ALL REQUIRED 1 TION AT 120914684422. COMPLETE DRAWING AT LOWER AREA PROVIDED. Qjt Sloned X Title 7 J—/L—49/ Date PLOT PLAN(Draw to Scale)Sole '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,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. 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. SEE ATTACHED L DEPARTMENT USE ONLY �v-�1'/J i/J/� /�1 Application Accepted By Date 0 �/ Area Grout Inspection By Date A A Pump Impaction By Das Deatructien Impaction By Date Comments: ACCOUNTING ONLY: AID* FAC* PE CODES FEE INF AM0UNT REM( TED CHECKJ/CAa RECEIVED BY DATE POWIT/SERVICER VEST NLW861 INVOICE