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FOR WELLIPUMP ION �r SAW JOAQUINTCOUNTY PUBLIC HEALTH R EIRV>iS ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201-88 1 (209) 468.3420 FJOH-RENUDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICompbte in T►iplieato) 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 STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. 290 N. Main St Manteca 223-091-01 JOB ADORE88/ORA,P�N,"R„, CITU PARCEL SIZE/APN# OWNER'S NAME_Edward J. & Dolores M. Cardoza ADDRESS P• 0. BOX ,1 022, Manteca, CA PHONE#(209)239-41-ti CONTRACTOR_V R W Tlri)l i ng ADDRESS P.O. BOX 51 ,Rio Vistaa►720904 PHONE#707 374-2819 SUS CONTRACTOR ADDRESS 94571 LICE, PHONE# TYPE OF WEL.UPIIMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# X3 OTHERGeOProbe/My#opunch ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J NA ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0 (TYPE OF PUMP) ❑.OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING g JMDESTRUCTION: Push point drilling with soil core & 4rab water sample INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 2t1 DIA.OF CONDUCTOR CASINO D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA.OF WELL CASING D ❑ PUBLIC/MUNICIPAL :0 DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E 1l MONITORING GROUT SEAL PUMPED: ❑Yee ❑No CONCRETE PEDESTAL BY DRILLER:❑Yes ❑Ne S APPROX.DEPTH 20' LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CON&TRUCTIONAXAILLING METHOD: MUD ROTARY AIR ROTARY AUGER 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'&COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN TH RFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'&COMPENSATION LAWS OF CAUFORNI THE APPUCAN MUOT CAIfh4 HOURS IN ADVANCE FOR ALL REGLXRED 1 9PECTIONG AT(2001400-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. �+ Slpned X Till Date PLOT PLAN(Draw to Scale)Scale '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. i .... .... ..... .................. ........... .. .. ................ .. .... _-- � DEPARTMENT USE ONLY Application Accepted By Date Area U Grout Inspection By - Date Pump Inspection By '' Date Destruction Inspection By Date Comments: ACCOUNTING ONLY: AID# FACE PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE A PERMIT/SERVICE REQUEST NUMBER INVOICE