APPLICATION FOR WELL CONSTRUCTION OR DESTRUCTION

THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED

Application is hereby made to the Stanislaus County Department of Environmental Resources (D.E.R.) for a permit to construct and/or destroy the work herein described. PLEASE NOTIFY THIS DEPARTMENT (USING PERMIT # AND D.W.R. WELL DRILLERS REPORT) WHEN WELL WORK IS COMPLETED.

JOB ADDRESS/LOCATION____________________________________________________ City__________________________

Distance & Direction from Nearest Cross Streets _________________________________________________________________

Owner’s Name_______________________________________________________________ Phone_______________________

Address ______________________________________________________________ City/State__________________________

Contractor's Name______________________________________________ License #____________ Phone_________________

TYPE OF WORK:(Check one)

NEW WELL      DEEPEN      RECONDITION   DESTRUCTION

OTHER ________________________________________________________________________

DISTANCE TO NEAREST:

SEPTIC TANK _________ SEWER LINES ________________________ PIT PRIVY_______________

OTHER WELL ________________ SEWAGE DISPOSAL FIELD ___________ SEEPAGE PIT ________

DRY WELL _______________________________ OTHER _________________________________

ANIMAL ENCLOSURE _____________________________________

CONSTRUCTION / DESTRUCTION SPECIFICATIONS

Dia. of Well Excavation __________________________

Dia. of Well Casing ______________________________

Gauge of Casing ________________________________

Depth Conductor Casing __________________________

Depth of Grout Seal _____________________________

Type of Grout ___________________ # Bags_________

Grout Manufacturer______________________________

Grout Name____________________________________

Well Destruction: Describe method if different than minimum state standards:__________________________________________

________________________________________________________________________________________________________

Existing well present?   YES     NO      Status:   Active      To Be Destroyed      Inactive

D.E.R. USE ONLY

Permit Issued by:_________________________________________Date:___________________

Permit Denied by:_________________________________________Date:______________(See Attached)

Grout Seal Inspected by:____________________________________Date:___________________

Final Inspection by:________________________________________Date:___________________

PLOT PLAN

(Indicate Distances in Feet)

1. Name of street and distance from nearest cross roads to well site.
2. Outline of the property, easements.
3. Outlines and locations of all existing and proposed structures, including covered areas such as patios, driveways, and walks.
4. Location of house sewer outlet, public sewer, sewage disposal system, or proposed sewage disposal system, proposed expansion of sewage disposal system, industrial waste pond, or any other possible source of contamination.
5. Location of other wells within radius of 300 feet on the property or adjoining property.
6. Location of sewage disposal system on adjoining property or within a radius of 100 ft. (private well) 150 ft. (public well).

NORTH ^

Written description of well location (if not visible from road):_________________________________________________________

I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH THE PROVISIONS OF THE LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE COUNTY OF STANISLAUS AND THE RULES AND REGULATIONS OF THE STANISLAUS COUNTY DEPARTMENT OF ENVIRONMENTAL RESOURCES (DER). DER WILL BE CONTACTED FOR INSPECTION OF ANNULAR SEAL INSTALLATION, AND AFTER WELL WORK HAS BEEN COMPLETED.

1. All existing wells within a 300 foot radius of the proposed new well(s) on the property or adjoining property have been located and so indicated.
2. Proposed well(s) will be located at least 50-100 feet from any sewage disposal system on property or adjoining property. Public well requires a distance of 100-150 feet from disposal system (100 ft. septic tank and leach lines, 150 ft. pits).
3. Submit well logs on all public wells drilled, as notice of well work completion.

SIGNED:______________________________________________________________

                (OWNER OR AUTHORIZED REPRESENTATIVE)

DATE:_____________________________