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f <br /> 3` w WELL 1 PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE Sae FL-STOCKTON CA 95202 - (209)468-3420 <br /> I NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> I - � <br /> a JOB ADDRESS CITY/ZIP <br /> t <br /> CROSS STREET APN � '+�"'�'"rARCEL SIZE USE APPLICATION# <br /> ? OWNER NAME2 ' PHONE <br /> � <br /> e7,0 /STATFIZIP <br /> OWNER ADDRESS <br /> CONTRACTOR ` PHONE iA � ` <br /> ff � <br /> CONTRACt OR ADDRESS 1 CITYISTATEIZIP <br /> SUBCONTRACTOR PHONE 14 <br /> SUBCONTRACTOR ADDRESS ITY/STATEIZIP <br /> LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other NUMBS EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> OIL <br /> INTENDED USE Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization b <br /> ' Public Water System <br /> If different from owner: Water System Name Contact amt or one umber 1� <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other p%,,� pW <br /> t "O❑Monitoring of Wells 13 Soil Boring(s) P[ n jflTGerm;( <br /> _EbLj <br /> X&t-Of-Service e 1 13 Out-Of-Service Well Renewal f <br /> ❑New Pum Pum Replacement ❑Pum Repair <br /> WELL CONSTRUCTIONV Pern lit 11 lay a expired without <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool wmmmm comes <br /> Proposed Well Depth ft Excavation in diameter ❑Openo'ii vlro I.Ips IOC ra1vel l size [�in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth � ttt�� <br /> Well Casing Diameter in Thickness/GaugUASTM Sched ❑Steel ❑Piastic O Stainless Steel ❑Other <br /> I Grout Seal Depth ft ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> 4 Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> e <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> C3 Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pi <br /> i <br /> PUMP Submersible ❑Turbine ❑Other HPPump Set R Standing Water Level ft <br /> I HEREBY CER FY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED —" TITLE DATE <br /> r _ <br /> 1 <br /> r <br /> r <br /> i <br /> t a <br /> - <br /> u <br /> A4 J1 A UI C U <br /> N 1R N E <br /> I <br /> FIT I I I E <br /> f <br /> D PA T M E N:T.1.0 Sy ON Y <br /> Application Accepted By rj Date <br /> Area [ t� <br /> Grout InspectionBy Date 13 SP A t <br /> Pump Inspection 8y Date WAIVEIitticV 2005Constructed Well Depth4u��� R JJ����``�� <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info By <br /> Cash RemittedDate Service Request# Invoice# Well ID# <br /> b Lit ! 020-0 a 5v.!f2-F'- <br /> er <br /> dna ✓ <br /> EL <br />