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T APPLICATION FOR INELLIPUMP PERMIT �N JOAQUIN COUNTY PUBLIC HEALTH SERVICO 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 (Complete in TFiplieatF) 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# CITY Tracy PARCEL SIZE/APN# OWNER'SNAMET4WV 33 Eight Of Way ADDRESS 1600 W. Diub NE# CONTRACTOR V&W Drilling ADDRESIP.O. Box 51 , LIC# PHONE#(7071374 2815 SUB CONTRACTOR ADD1E%0 V]Sta' CA 945-11 UC# PHONE# TYPE OF WEWPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL MONITORING WELL#_—L-4yZdj ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J ❑Nev+❑Repalr H.P. DEPTH PUMP SET__FT. FIRST WATER LEVEL 0 ITYPE OF PUMPIB ❑ OUT-OF-SEflVICE WELL ❑ GEOPHYSICAL WELL# SOIL BORING ❑DESTRUCTION: A INTENDED USE TYPE OF WELL CONSTRUCTION ❑ INDUSTRIAL ❑TI OPEN BOTTOM o DIA.OF WELL EXCAVATION R _ S 1 DIA.OF CONDUCTOR CASING D ElDOMESTIC/PRIVATE W 3 GRAVEL PACK/SIZE � TYPE OF CASING/STEEL/PVC 4 O P V C DIA.OF WELL CASING 211 D ❑ TUBUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL 0–4 1 SPECIFICATION R ❑/I IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED 1�BBFYTrlRLhiling GROUTBRANDNAMCemnetpp/lI4% Bent E 0 MONITORING GROUT SEAL PUMPED: le#Y. [3 N. CONCRETE PEDESTAL BV DRILLER23 Vm ❑No S APPROX.DEPTH 7 n 1 LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTION/DRIWNG METHOD: MUD ROTARY AIR ROTARY AUGER 1-1� 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:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL NOT EMPLOY SONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THEM RANCE OF THE WORK FOR WHICH THIS PERMTT IS ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'e COMpENSAMN LAWS OF ' E CAUFORNIAAPPLICANT BT CA ZURS IN ADVANCE FOR ALL REQUIR INSPECI7 Ne AT UtOGN X53439. COMPLETE DRAWING AT LOWER AREA PRO DED. Slynetl% Titl / t -Q� �LG� .Q_Af Data I PLOT PLAN ID,.to SA.)r W 3 to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 6. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION F SEWAGE DISPOSAL SOF ON 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF TY O WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. SEE ATTACHED MAP ; ........ . .. .. ........... ... PAYMENT" "ECEIIIED .. Z b 19'h-7 E 00 AN>vJ i,i r S BLICHE� t NUfROfVMEN ti 's t „t, 1.. r� DEPARTMENT USE ONLY Appllmtlon Accaptetl BY Det. I 1 V L7 Area Grout Impmtlon By Date PumP by tlon By Dab Det. Dmtruotlon Imp.otion By Comment.: GPrL"f12W5 E�crc�ichrrnnl- l�q� -loSu- b15� ACCOUNTING ONLY: AID# FAC# PE CODEb FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE 35b Da3�5 N I� 012 1 L4