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APPLICATION FOR WELL)PUMP PERMIT <br />SAN JOADUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201-388 <br />(209) 468-3420 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete in Triplicate) <br />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 <br />JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR APN# 1603 South B Street CITY Stockton PARCEL SIZE/APN# _ <br />OWNER'S NAME Cly Department of Transportation ADDRESS 1976 Charter Way a PHONE#209-948-7873 <br />CONTRACTOR Geocon Environmental Consultants ADDRESS 3235 Sunrise Blvd LIC# PHONE#916-852-9118 <br />SUBCONTRACTOR Westex, Inc. ADDRESSPO Box 1664 W. Sac_IC#-65;-;?( 6r PHONE#916-373-1118 <br />TYPE OF WELL/PUMP: 12NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL # ❑ OTHER <br />❑ INSTALLATION 15? WELL SYSTEM REPAIR ❑ CROSS -CONNECT REPAIR ❑ VAPOR EXTRACTION WELL # <br />❑ New ❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL C' <br />(TYPE OF PUMP) <br />❑ OUT -OF -SERVICE WELL ❑ GEOPHYSICAL WELL # ❑ SOIL BORING B <br />❑ DESTRUCTION <br />INTENDED USE <br />TYPE OF WELL <br />CONSTRUCTION SPECIFICATIONS <br />A <br />❑ INDUSTRIAL <br />❑ OPEN BOTTOM <br />DIA. OF WELL EXCAVATION <br />1011 <br />DIA. OF CONDUCTOR CASING NJ A O <br />❑ DOMESTIC/PRIVATE <br />❑ GRAVEL PACK/SIZE #3 Mon— <br />TYPE OF CASING/STEELJPVC <br />PVC <br />DIA. OF WELL CASING 411 D <br />❑ PUBLIC/MUNICIPAL <br />❑ DRIVEN tery sand <br />DEPTH OF GROUT SEAL <br />151 <br />SPECIFICATION R <br />❑ IRRIGATION/AG <br />%OTHER <br />GROUT SEAL INSTALLED BY <br />Westex <br />GROUT BRAND NAME�1---IIJ E <br />9 MONITORING <br />GROUT SEAL PUMPED: 9 Yes <br />❑ No <br />CONCRETE PEDESTAL BY DRILLFR: 5aYes LNo S <br />APPROX. DEPTH 100 1 <br />LOCKING CHESTER <br />BOX/STOVE PIPE <br />S <br />PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY <br />AIR ROTARY <br />AUGER X <br />CABLE OTHER <br />I HEREBY CERTIFY THAT I HAVE PREPARFD THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND <br />REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br />THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUB -CONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: " I CE IFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CALIFORNIA.' AP CANT MUST C LL 24? IN DVANCE FOR ALL REQUIRED IN§rt�CTION9 T (20"1 4683423. COMPLETE DRAWING AT LOWER AREA PROVIDE <br />Signed X� �� l'L���� Title �y 1,_ �-Yl /�7t? P-� C /�� `-1 Data `� <br />PLOT PLAN (Draw to Scale) Scale " to <br />1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />2. OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED B. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br />V1 <br />0 <br />Application Accepted By <br />DEPARTMENT USE ONLY <br />DatO I �y Area <br />/J <br />3�6- <br />Grout Inspection By <br />Date - ` T r� l S Pump Inspection By <br />Date <br />AMOUNT REMITTED <br />Destruction Inspection By <br />RECEIVED BY <br />Date <br />/SERVICE REOUE INVOICE <br />Cemm W \kt oo v- O)c <br />Tyyr kj'l ( c <br />ACCOUNTING ONLY: <br />AID# <br />r FAC# <br />PE CODES FEE INFO <br />AMOUNT REMITTED <br />CHECK#/CASH <br />RECEIVED BY <br />I DATE <br />/SERVICE REOUE INVOICE <br />