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• APPLICATION FOR WELLIPUMP PERMIT 11N JOAOUIN COUNTY PUBLIC HEALTH SERVIIP ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445 N. SAN JOAQUIN ST, STOCKTON, CA 95201388 (209) 4683420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Cfmplftf In TrIplinte) 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 ADDRESSOR APN# Z 5�s —3 I d — Z 1 CITY Trazv PARCEL SIZE/APN,I OWNER'SNAME Milton Birkham ADDRESS 1697 West Durham Fe ONEe83(5-47213�w CONTRACTOR V & W Drilling ADDRESSP. cx0,.•1..,Box 51 Uci 4 PHONE K`707)37`YW15 94571 SUB CONTRACTOR ADDRESS vista, UCN PHONE N TYPE OF WEUJPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL MONITORING WELL# I tAx It ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL J ❑Na 13 P elr H.P. DEPTH PIMP SET—FT. FIRST WATER LEVEL 0 (TYPE OF PUMP) ❑ OUT-OF-SERVILE WELL ❑ GEOPHYSICAL WELL R ❑ SOIL BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑I� OPEN BOTTOM y� DIA.OF WELL EXCAVATION 8.5 DIA.OF CONDUCTOR CASING D 2 ❑ DOMESTIC/PRIVATE 1GRAVEL PACK/SIZE #3 TYPE OF CASING/STEEL/PJC nn40� TAW DIA.OF WELL CASING 2" D POO-'L ❑ BUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL I SPECIFICATION R r❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY TLvmm1T3 GROAT BRAND NAME�[E31t. 4=6 ]�. E vf WI MONITORING GROUT SEAL PIMPED:WY. ❑No CONCRETE PEDESTAL BY DRILLER:MrY. [IN. S APPROX.DEPTH ?pI LOCKING CHESTER BOX/STOVE PPE S PROPOSED CONSTRUCTIONR1mWNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HERESY 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 JOAOUIN COU! . HOME OWNER OR UCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMP PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORWIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOW -I CERTIFY THAT IN T ERFORMANCE OF THE WORK FOR WHICH HIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORI0.IAN'f CO PENf TION LAWS OF CAUFORNI TH APP CANT BT M Olmf IN ADVANCE FOR ALL REGUIR INS NS AT IZOB . COMPLETE DRAWING AT LOWER ANSA PROVI D. 9lpned X /TI OOOOVV////////// De. PLOT PLAN IDrew to fhMa)8uls 'to AN 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 3. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTUNFS 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. �yy.,,y� ".. ..... ...... .... ........ .... ...... . DEPARTMENT USE ONLY Appllmtlon Accepted By DM. I ` L I Y I' Are. Grout Impeetlon By Date Pump Inepettlon By Det. DWrmtlon Imp. lo`n�By^C!, �,. � Q,� �D�ate�,. Comment: / lsrpJJ ��I u'�• ' _ - ' ev, � lr ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECOVED BY DATE PFRMITISERVICE REQUEST NUMBER INVOICE p BF (bi ydL{- 01 21