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' WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT w 304 E WEBER AVE 3"°FL-STOCKTON CA 95202 - (209)468-3420 4 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES l YEAR FROM DATE ISSUED L <br /> 1� /} :q <br /> JOB AaDRE55 7 7 A -v V-j oc "� ITY/ZIP - <br /> v <br /> 11 n� d <br /> _APN !I6'2�' PARCEL SIZE �ff Qh t LAND USE APPLICATION# <br /> CROSS STREET S} l/JI1w nib- II -260- I D t -A <br /> —11 <br /> Jr+j �G S-1�LCG rJ� PHONE_y?7 --4$2.( i <br /> OWNER NAME 1 <br /> ,� 2 �[-L/{�{� G1�•�IG Cl/s CITYISTATEIZIP 'GCI�/'���� <br /> OWNER ADDRESS <br /> PHONE ?'Qj G -37CD 1 <br /> CONTRACTOR <br /> �l CITY/STA t. ` <br /> CONTRACTOR ADDRESS _ 7 o2 d 0�SRI M <br /> PHONE <br /> i,a <br /> SUBCONTRACTOR EE' <br /> CITv15TATE1Ziernm may have expired witbauL <br /> SUBCONTRACTOR ADDRESS {'Jy�' <br /> I S PrI � � e <br /> Pd <br /> X } <br /> LICENSE ❑C-61 ❑D-09 ❑Other NUMBER m'Ran ahs ot_on <br /> Y TwnslipiorD'� tpl <br /> GEOGRAPHICAL INFORMATION: Coordinates X <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑industrial ❑Water Quality Monitoring IPoil Sampling/Characterization <br /> ❑Public Water System ares ystem ame Contact Name or one NUMDer <br /> If different from wner. <br /> TYPE OF WORK: ❑New Well M Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other ft of borings U� <br /> p of borings ❑Geotechnical <br /> y ❑Monitoring Well(s) #of wells `P Soil Boring(s) <br /> I ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal <br /> ❑New Pump ❑PumR Replacement ❑Pump Repair ❑Cross-Connection Repair <br /> WELLCONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary Auger ❑Cable Tool ❑Push Point ❑Other <br /> I Proposed Weil Depth -5— 15 R Excavation in diameter ❑Open Bottom ❑Gravel Pack 1 Gravel Size in diameter <br /> ❑Conductor Casing in diameter 1 Conductor Casing Depth ft $ <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched 13Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 Ib bag/5-10 gal water) ❑Sand Cement ruck mix/7 gal water <br /> ❑Bentonite(201/6 solids) ❑Manufacturer Spec%solids % Name lApecs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant I Accelerator(name) TC <br /> � W- <br /> i PEDESTAL Installed B 11 Driller ❑Pump Contractor 13 Other <br /> El Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Sox 11Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <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 COMPENSATION LAWS. <br /> 1MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED <br /> Cvu}t TITLE 57?!f DATE 2 Zai <br /> -� <br /> DN <br /> .afffR � f <br /> 4+ (TW 111 LU A <br /> -�•� rip i � <br /> o '3 E <br /> tCbENE <br /> 5 <br /> ' ! AN d0 Q 40 AL <br /> rMme D P FIT EfIT <br /> [ j C7 <br /> A _ <br /> PARTUM ENT U NLY / <br /> Application Accepted B , Date7/6, Area _/ 1 Employee ID#i 3/ <br /> Grout Inspection By Date ❑ SPECIAL Well Permit / <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Destruction Inspecti BY Date Constructed Well Depth ft <br /> COMMENTS 5 <br /> ' PE SC Received eck#1 -,Amount Date Permit/ invoice# Well]DO <br /> Codes Info B Cash Remitted Service Re nest# <br /> I <br /> 173 0 q 7� <br /> WELL PUMP PERMIT <br /> EHD 43-02-006 <br /> sh I04 <br />