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APPLICATION FOR WELL(PUMP PERMIT . - - • , aAN JOAQUIN COUNTY PUBLIC HEALTH SERVI e ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445 No SAN JOAQUIN ST., STOCKTON, CA 95201 .388 (209) 468.3420 NONREFUNDABLE PERMIT EXPIRES I YEAR FROM 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 STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN% Adjacent to 701 E . Charter Wa }EITy Stockton PARCEL SIZE/APN% OWNER'S NAME Darpetro , Inc . ADDRESS 3450 Ei Camino , Ceres , Ca . PHONE % 537 - 0771 CONTRACTOR Spectrum EXploation ADDRESS 2825 EoMyrtlest uc4512268 RHONE % 465 - 8712 SUB CONTRACTORrrv- ADDRESS UC% PHONE % 13TYPE OF WELUPUMP: 13 NEW WELL ❑ REPLACEMENT WELL 1..4 MONITORING WELL # 12 ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL J 13Naw 13Repair H.P. DEPTH PUMP SET_FT. FIRST WATER LEVEL O TYPE OF PUMP) ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL % [3 SOIL BORING 8 ❑ DESTRUCTION: INTENDED USE TYPE Of WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WELL EXCAVATION T1 DIA. OF CONDUCTOR CASING O ❑ DOMESTIC/PRIVATE ❑ GRAVEL PACK/SPE 02 TYPEOFCASING/STEEL/PVC PVC DIA. OF WELL CASING 211 D ❑ PUBUC/MUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL 35 SPECIFICATION R ❑ IRRIGATION/AG ❑ OTHER GROUT SEAL INSTALLED By S p e c t r u m GROUT BRAND NAME Cement E t] MONITORING GROUT SEAL PUMPED: ❑ Ys 11 No m CONCRETE PEDESTAL BY DRILLER: ❑ Ys ❑ No S APPROX. DEPTH 8 5 LOCKING CHESTER BOX/STOVE PIPE T r a f f i c B o x S PROPOSED CONSTRUCTION/daWNG METHOD: MUD ROTARY AIR ROTARY AUGERX CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPIJCATION 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: "I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH 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 THE FOLLOWING: ^ I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WOI MIAN'S COMPENSATION LAWS OF CALIFORNIA," THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 1200) 9533623. COMPLETE DRAWING AT LOWER AREA PROVIDED, SignetlX Title Consultant Data10 / 2 / 95 PLOT PUN (Draw to Gene) Scale ^ to 1 . NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING 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 Fr. STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. DEPARTMENT USE ONLY Application Aaceptei By . Date* . //; L Area Grout Inspection By Date Pump Inspection By Date Destruction Inspection By Date Comments: ACCOUNTING ONLY: AID% TZ ACO CODES FEE INFO AMOUNT REMITTED CN /CASH I RECEIVED BY DATE PERMIT/SEAVICE REQUEST NUMBER INVOICE �/ lrl