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" APPLICATION FOR WELLIPUMP PERMIT :, %.AN JOAOUIN COUNTY PUBLIC HEALTH SERYL,,_ ENVIRONMENTAL HEALTH DIVISION .. ._. P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA SE201.386 t (209) 488.3420 I E NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ¢ (Complete 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 5-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBUC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. M, JOB ADDRESWOR APN* 118-3-090-04 CITY IZ PARCEL SIZFJAPN* OWNER'S NAME Ban1=PtcY Estate of L Moresco ADDRESS P• O- BOx 501,8, Mod 95353 PHONE* 524-1793 CONTRACTOR V & W Drilling Inc. _ -ADDRESS P. O. Box 51 Rio eta 720909p„,,(E7,r07)374-2815 f SUB CONTRACTOR ADDRESS UC* PHONE* ; TYPE OF WELLIPLIMP: Q NEW WELL. ❑ REPLACEMENT WELL ❑ MONITORING WELL.* ❑n OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR Q'CROSS-CONNECT REPAIR VAPOR EXTRACTION WELL* 4 _ jI ❑New❑Repair H.P. DEPTH PUMP SET FT, FIRST WATER LEVEL O irYPE OF PUMP) 13E OUT 11-OF-SERVICE WELL GEOPHYSICAL WELL* ❑ SOIL BORING 8 ❑DESTRUCTION: i INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 10, DIA.OF CONDUCTOR CASING D ❑ DOMESTICIPRIVATE IN GRAVEL PACK/SIZE TYPE OF CASING/STEELlPVC PVC'_ DIA.OF WELL CASING 411 D ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL, 20 1 SPECIFICATION Sch 40 R :i Cement ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY Z GROUT BRAND NAME F ® i MONITORING GROUT SEAL PUMPED: [2Yes [IN. CONCRETE PEDESTAL BY DRILLER:i:I Yes ❑No S APPROX.DEPTH 4-51 LOCKING CHESTER BoxlsTOVE PIPE s' PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER X CABLE OTHER ' r I HEFIEBY 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 PERSONS SUBJECT TO WORKMAN'S COMPENSATFON 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 WORKMAN%COMPENSATION LAWS OF CAUFORNI THE APPUCAN .MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED FNSPEC QNa AT(2001 4A83423• COMPLETE DRAWING AT LOWER AREA PROVIDED. Signed X Title Date I PLOT PLAN{Drew to Scale Sc Is 'to f 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 i 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. ...............See..Attached.. ........ ........ ........ .. .. E y M F DEPARTENT USE ONLY Application Accepted By Area Date til 1 U -I' I 904 Grout Inspection By Date (Pump Inspection By Date i Destruction Impactioni / BY pats , Comments: k :COUNTING ONLY: AID* HECK* FAC* 'ODES FEE INFO AMOUNT R061ITTED ASH RECEIVED BY' DATE PEFW3T/SERVICE REQUEST NUMBER INVOICE I