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APPLICATION FOR WELLIPUMP PERMIT �N JOAQUIN COUNTY PUBLIC HEALTH SERVId ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201-388 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IComplate in Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR 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 API# Z SS—3I o _ Z3 CITY, Tracy PARCEL SI2E/APN# OWNER'SNAME Muriel Jones ADDRESS 31448 S. Hwy 33 PHONE# 835-1401 CONTRACTOR V& W Drilling ADDRESS P. 0. BOX 51 LIc#720904 MONA707)374-2815 SUB CONTRACTOR ADDRESS Fdo Vista, M 9457111CN PHONE III TYPE OF WELL/P11MP: 13 NEW WELL ❑ REPLACEMENT WELL I�MONITORING WELL VY # 1 ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL# ✓ ❑New❑Ranalr M.P. DEPTH PUMP SET—FT. FIRST WATER LEVEL O (TYPE OF PUMP) ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL M ❑ SOIL BORING S ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL 0OPEN BOTTOM DIA.OF WELL EXCAVATION 8.S1 DIA.OF CONDUCTOR CASING O ❑ DOMESTICYrVATE CJJ GRAVEL PACK/SIZE#3 TYPE OF CASING/STEEL/PVC 40 m DIA.OF WELL CASING 211 O ❑ PUSUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL 0 4' SPECIFICATION ,.,�— , R [IIRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY `IYIIUITYT GROUT BRAND NAMECtTE It 4CY ❑3 �It E Ix MONITORING GROUT SEAL PUMPED: ®Yea [INoCONCRETE PEDESTAL BV DRILLER:CJ Yr No S AppalDEPTH 20' LOCKING CHESTER BOX/STOVEPIPE S PROPOSED CONSTRUCTION/ UJNG METHODICABLE : MUD ROTARY AIR ROTARY AUGER 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:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPL07NS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SU"ONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE K RMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WOIIKMAX'S COMPENSATION LAWS OF CAUFORN/I♦/yy��/LpE^AyP_/P',ICAlN1(T/B1/Jy-Y/T//y/��//�/� 1lR�U�X/JS�IX,/A��V�ANCE FOR ALL REOUNLED/�1111�,,P[CTMXN/T IZ�MI41SS�-3L/2It.�^COMRE'fE DRANANO AT LOWER AREA *DED. SiSnod X'/ '.f/'tI',-�-/��u,%�jT/ -` r" 'i-�!��'l.�"""ice i Title/\Yl R /�I:J.C��L1LW✓t-'L Dna 7 PLOT PAN(Oren to _molal Bo l. '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 PROPEWY. SM 70PERD.NYIP ....: s. ............ ........._. i DEPARTMENT USE ONLY Application Accepted Byrnj� Data 1 Y i ✓ At" Grout Impectlon By Data Pump Irupecticn 8y Date Destruction Insp/e ttnn'By /Iy,.,, ^,, ,u n ,. rW1- �/-y Tl-^� I,r ��A Date Commants: / cam -)Axl(lJ�+'�s'•`�"" ", � 1'-� u`^' l��Q ��{�,1�(tv/ ACCOUNTING ONLY: AID/ FAC# PE DOOM FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMITIS6RIICE REQUEST NUMBER INVOICE 5bl b� 3`15 l{ 14g 12 � y8