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r <br /> WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3a"FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT : CALL(209)953-7697 FOR INSPECTIONS EXPIRES l YEAR FROM DATE ISSUED <br /> JOBADDRESS CITY/ZIP <br /> y <br /> CROSS STREET Citi APNA666LAW PARCEL SIZE AND USE APPLICATION# <br /> /J) <br /> OWNER NAME V f] PHONE <br /> OWNERADDRES IU TYISTATEIZdfC � D/ / a � <br /> CONTRACTOR (i( I I L/J — PHONE 79z� <br /> CONTRACTOR ADDRESS CITYlSTATEIZIP <br /> -- i <br /> i <br /> SUBCONTRACTOR PHONE i <br /> SUBCONTRACTOR AD CITY/STATE/ZIP <br /> LICENSE -57 ❑C-61 ❑D-09 0 Other NUMBER ` EXPIRATION DATE ' <br /> GEOGRAPHICAL INFORMATION: Coordinates Y o Ih] ahgery tion <br /> INTENDED USE ❑Domestic/Privaterrigation/Agricultural ❑Industrial Water Ouaritf r4orilorAg tl Sa li eterization <br /> ❑Public Water System 1 <br /> If different from Owner: Water System Name r o e 4rl <br /> TYPE OF WORK ❑New Well ❑Replacement Well 0 Well Alteration/Modification I gt or inspuLted <br /> O Monitoring Well(s) #o£wells ❑Sail Bonin s °tl� r 3, (borings ! <br /> ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal <br /> ❑New Pump 0 Pump Replacement ❑Pump Repair ❑Cross-Connection Repair <br /> WELL CONSTRUCTION <br /> Drilling Method M-Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point Other <br /> Proposed Well Depth, ft Excavation /if diameter ❑Open Bottom Gravel Pack!Gravel Size-4—&/41-1 diameter l <br /> ❑Conductor Casing in diameter / Conductor CasingDepthft <br /> Well Casing Diameter 4..-_in Thickness/Gauge/ASTM Sched 11 Steel Plastic ❑Stainless Steel 13 Other <br /> Grout Seal Dept - M R ❑Neat Cement(94 lb hag 15-70 gal water) ❑Sand Cement .tack mix/7 gal water <br /> entonite(20%solids) ❑Manufacturer Spec%solids % Name GQOL)7-G gfL DIC Dees on File ❑Specs Submitted <br /> Grout Placement Method �mped ❑Free Fall ❑Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By n 0 Driller @r5ump Contractor ❑Other' 0 � <br /> ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box 0 Stove Pipe <br /> PUMP CI Submersible ❑Turbine ❑Other HP Pump Set i It Standing Water Level ft <br /> WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other <br /> 11 Total th Depth t ft CP <br /> er to <br /> 3 li Material ❑Neat m Ib h -1 a1 ware ❑Sand <br /> merit <br /> mix C7 tonite ets <br /> Be /o sol ) ufa ren Sp /o solids me 5p ❑ ittPlacem Method ❑Pu F Fa Othero lete wit u oo ap low grade ❑Co 1g fac ad <br /> I 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. 1 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 /> WORKERSCOMP ON LAWS. '' - <br /> MI IMUM 24 HOUR ADVANCE NOTICE Ul R INSPECTIONS <br /> SIGNED TITLE DATE <br /> ftew 44 4L <br /> 7 <br />" --�-' .r' DEPARTMENT USE ONLY <br /> Application Accepted By Date Area Employee ID#� � <br /> Grout Inspection By Date ❑ SPECIAL Well Permit III <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Destruction Inspection By fi Date " Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info B as Remitted Date Service Request# Invoice# Well ID# <br /> EHE 43.02-006 MASTER WATER WELL PERMIT j <br /> 12/2272003 - n <br /> f <br /> I <br /> Y <br />