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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT 'A r q <br /> EXPIRES 1 YEAR FROM DATE ISSUED <br /> Jos ADDRESS <br /> � '�''I <br /> CITY/ZIPrn <br /> CROSS STREET APN —PARCEL 592F- LAND USE APPLICATION# <br /> OWNER NAME 1, �r,tlyy , <br /> PHONE <br /> OWNER An DRESS CITY/STATFIZIP k <br /> CONTRACTOR <br /> PHONE <br /> CONTRACTOR ADDRESS /1' 1- <br /> r.1 ir CITYiSTATEIZIP­S li.:':IL <br /> SUBCONTRACTOR k PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP-.c y <br /> LICENSE C-57 C-61 0-09 Other NUMBEREXPIRATION DATE //Z <br /> GEOGRAPHICAL INFORMATION: Coordinates X y <br /> Township— Range_ Section <br /> INTENDED USE Donieslic/Piivale Irrigalion/AgriCUIlLfrat IndUstrml Water Quality Monitoring Soil Sampling/Characterization <br /> Public.Water System <br /> If different from Ova ter <br /> TYPE OF WORK New Well Replacenietil Well Well Alteration/Modification Other <br /> Monilor4ig Well(s) #0twells Soil Bolin g(s)— ft of bmings YuGeotechnical #of borings <br /> Out-Of-Servfce Wel9 Out-Of-Service Well Renewal Cross-Connection Repair <br /> New PLIHIP PUH)p Replacement Pump Repair <br /> Raise Well Casin <br /> WELL CONSTRUCTION <br /> Drilling Method 6 Mud Rotary Air Rotary X Auger Cable Tool Push Point Other <br /> Proposed Well Depth./6 ft Excavation in diameter OpelT Roltorn Gravel Pack/Gravel Si7e. in diameter <br /> Conductor Casing_it,diFIjnetF,,r I COndUCIOr Casing Depth ft <br /> Well Casing Diameter in ThicknesslGaugp/ASTIVI Sched— Steel PlasticStainless Steel Other <br /> GroutSeal DepthftNeal Cement(94 fb bagl5-10 gal water) Sand Cement sack nVW7 gal water <br /> Bentonite f2O%solids) Dlher <br /> Grout Placernent Method ',;�< PLjmped Free Fal( <br /> Other Retardant/Accelerator(name) <br /> PEDESrAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width <br /> It Length_I't Thick in Christy Box Strye Pipe <br /> PUMP Submersible, TUihire Other— illp Flunip Set_it Standing Water Level ft <br /> I HEREBY CERTIFY 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 COMP;IENSATION LAWS. <br /> SIGNED TITLE L <br /> DATE <br /> ---------- <br /> -7- <br /> ji L <br /> D E P A It T IM E N T U 2 E 0 IN LY <br /> Application Accepted By ........... .......................— Date Area Employee ID# <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump lnspeclion By <br /> Date WAIVER Received <br /> Soil Boring Inspection By <br /> Date Constructed Well Depth ft <br /> COMMENTS Z ... .... ...... <br /> ........... <br /> .......................... ....... <br /> ........... <br /> PE SIC Received .—'Check#1 Anic;unt Pern ill <br /> Codes Info C..asli' Remitted Date Service Request# Invoice# WL-11 ID# <br /> 01 <br /> A>0 <br /> rd <br /> WEI-L/PUMP PERMIT <br /> ............ .. ....................................... ........ .... . ...................... ........................................................................................................................ <br />