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P'' APPLICATION FOR WELL/PUMP PERMI i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVWES ENVIRONMENTAL HEALTH DIVISION ;. P°O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In Triplints) 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 TITLE1,CHAPTER 9-11/15.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APN# .;a175 f`-�I `W n 1 CITYy 1�N1�1-1 �-/�� ♦ PARCEL SIZE/APtJ/ �L_I bo"�y+� OWNER'S NAME (AN CCDM PANy ADDRESS�3s27 S H WY 33.V a--iVVgr1, 1'- PHON�E�yl� yS76� ,y1�+ CONTRACTOR ViW DRILLWb, INC• ADDRESS �tl945 uc, i7-090q PHONE+ "•L� SUB CONTRACTOR ADDRESS '"""• LIC# +"a PHONE 0 TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL r ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL p ITYPE OF PUMP) ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONSS � A 11 INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 9.09•" DIA.OF CONDUCTOR CASINGS 1'>4e 4 D ❑ DOMESTIC/PRIVATE 11 GRAVEL PACK/SIZE TYPE OF CASINO/STEEL/PVC '3C14,40 f`V DIA.OF WELL CASING 21�VY D ❑ PUBLIC/MUNICIPAL 11DRIVEN DEPTH OF GROUT SEAL SPECIFICATION .'N.y..4Q R ❑ IRRIGATION/AG 11 OTHER GROUT SEAL INSTALLED BY <M�� GROUT BRAND NAME 9 VAT f I"MF,Xr E ❑ MONITORING GROUT SEAL PUMPED: ❑Y. [IN. CONCRETE PEDESTAL BY DRILLER:❑Yr [IN. 3 APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTION/DAILUNO METHOD: MUD ROTARY AIR ROTARY AUGER 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:-1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK 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: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOUMED INSPECTIONS AT(20914"4423. COMPLETE DRAWING AT LOWER AREA PROVIDED. - fes Signed X �C�-'�"( Title 'MQ:)1 Ir ' Data PLOT PLAN(Draw to Scale)Scale 'to 1. NAMES OF STREETS OR ROAD$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 PROPERTY. .......'.........'._....i.................................:.......i..... .. .. .......i.............i....... � ........ .. .. .. .. .. ... i Cpt,1 ........... .. .. .civ : ................... AIR '�4 ..bE trill ................... . .. �. #A 411 _. . . . ... .. :44 1�6 ... .. .. . :.... : .. . 'KA 0L .... ..................I. ....... ... ......... ...... ....... . . ..... N ... ...... .. . . ............. ... ........ . ....:... .....:...... . .. ... ..... DEPARTMENT USE ONLY f Application Accepted By I/ /' .!/ .! Date 1 Area Grout Inspection By Date Pump Inspection By Date - Destruction Inspection By Date Comments: - ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMITMERVICE REQUEST NUMBER INVOICE