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F = v-:- WELL J PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"°FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT C.ALL(209)953-7697 FOR INtiPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> ` �2ji9/Y' L�fY � T <br /> JOB ADDRESS CITY/ZIP > <br /> � /rte D <br /> CROSS STREET / S/s'� /i T/�/_�+'APN Za2:- 7e �{ _PARCEL SIZEr3LAND USE APPLICATION#Q <br /> OWNER NAME \ /l //f�M L�/�G! �PyHJOfNEE <br /> OWNER ADDRESS !2 7-5-7 '✓fZRY CITYISTATEIL[P ///f/�!CL <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITV/STATE/ZIP <br /> LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other Num s+� ExIZURi <br /> ri Y V <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑Dornestic/Private ❑Irrigation/Agricultural ❑Industrial expi i] Qtharacterization <br /> ❑Public Water System <br /> If different fromOwner- Seater System Name e <br /> fth <br /> ion <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification L 6s[h6lb t <br /> ❑Monitoring Well(s) #ofwclls ❑SoilBoring(s) Hofborings CJ Geotechnical tlofborings <br /> ❑Well Destruction ut-Of-Service Well ❑Out-Of-Service Well Renewal <br /> ❑New Pum ❑Pump Replacement ❑rump R air ❑Cross-Connection Repair <br /> WELL CONSTRUCTION S <br /> Drilling Method ❑Mud Rotary El Air Rotary ❑Auger 13 Cable Tool ❑Push Point 13 Other <br /> Proposed Well Depth ft Excavation in diameter <br /> El Bottom 11 Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft \ <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth tt ❑Neat Cement(941h bag/5-10 gal water) ❑Sand Cement .sack mix 17 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fail ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other <br /> ❑Concrete Pedestal Dimensions: Width ft Length _ ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other <br /> Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from ft to ft <br /> Sealing Material ❑Neat Cement(94 lb(rag/S-10gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite Pellets <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Placement Method ❑Pumped ❑Free Fall ❑Other <br /> 0 Complete with Mushroom Cap it below grade ❑Complete to Existing Surface Pad <br /> 1 HEREBY CERTIFY THAT 1 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 ENSATION LAWS. <br /> INIMUM 24 HOUR ADVANCE NOTICE <br /> //REQUIRED FOR INSPECTIONS <br /> SICNE TITLE /�Lr1/1/ . DATE <br /> � t . <br /> J <br /> / <br /> T <br /> DEPARTMENT US ONLY <br /> Application Accepted By Dat Area C Employee ID# <br /> Grout Inspection By LJaW__ 0 SPI=rIAI.We"ormit / <br /> Pump Inspection By ❑ WAIVER Received <br /> Destruction InspectionBy. Date Constructed Well Depth ft <br /> COMJMS TS s`� J <br /> f 1— <br /> PE SC Receivedec Amount ate Permit/ Invoice q Well III# <br /> Codes Info By Remitted Service Reguest# <br /> EHD 43-02-OM MASTER WATER WELL PERMIT <br /> 12 22 200 <br /> 1 <br />