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r <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 85205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />CALL 209 953-7697 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />Conductor Casing in diameter / Conductor Casing Depth R <br />A' <br />-'O <br />JOB ADDRESS <br />CITYIZip <br />^V I7IV�I I <br />CROSS STREET <br />APN l) J 7-3A— 1 ) PARCEL SIZE _LAND <br />USE APPLICATION <br />OWNER NAME <br />ci hr <br />\_ <br />PHONE <br />OWNER ADDRESS I (a3l Mi <br />1 <br />i 1 r D r (/ iy7-, CnYlSTATE/Z1P <br />��� <br />%��y a <br />�-,N6 —2- <br />CONTRACTORuov <br />I <br />PP�HHONE / 1 <br />A�15b3a- <br />CONTRACTOR ADDRESS <br />CITYISTATEIZIP I��IIJ7 <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITY/STATE/LP <br />3 <br />J <br />—3JZ <br />LICENSE C-57 -61 <br />.. D-09 .- Other NUMBER-`� <br />ExpwATION DATE <br />GEOGRAPHCAL INFORMATION: Coordinates X Y Township_ Range Section <br />NTENDED USE Domesbc/Privale _. Irrigation/Agncu tural Industrial Water Quality Monitoring = Soil Sampling/Characterization <br />Public Water System <br />If dlffererii Nom Ow"r W.er Syst— eme U.ntd N- or Fbo. m <br />TYPE OF WORK 1( New Well - Replacement Wel _. Well AlterationlModificalion . Other <br />C Monitoring Wells) # of wells - Soil Bonng(s) # of bodogs Geotechnical s of borings <br />Out -Of -Service Wel - Out -Of -Service Well Renewal - Cross -Connection Repair <br />Y. New Pumo - Pumo Replacement Pumo Repair Raise Weil Casino <br />Drilling Method X Mud Rotary Air Rotary - Auger - Cable Tool - Push Pant - Other j <br />Proposed Well Depthft Excavation � in diameter - <br />Open Bottom �iGravel Pack/Gravel Size in diameter) <br />Conductor Casing in diameter / Conductor Casing Depth R <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched tits ;�-nQ = <br />Steel X Plastic -- Stainless Steel -.. Other <br />Grout Seal Depth2:tj)_R - Neat Cement (94 lb bag/5-10 gal water) <br />X Sand Cement I Q,3 sack mixl7 gel water. <br />_ Bentonite (20% solids) _ Other <br />Grout Placement Method X Pumped _ Free Fall -. Other _ <br />Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller ._ Pump Contractor 011ier <br />Concrete P destal -Dimensions: Width It Length <br />R Thick n Christy Box Stove Pipe <br />PUMP V Submersible - Turbine Other HP <br />Pump SetLLE2R 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 COMPENSATION LAWS. <br />DEPARTMENT USE ONLY <br />Application Accepted By Dale Area Employee ID# <br />Grout Inspection By Date ] SPECIAL Well PerMit <br />Pump Inspection By Date I WAIVER Received <br />Soil Boring Ins tan By Date Constructed Well Depth ft <br />COMMENTS <br />PE SC Received Check#/ Amount Date P. -V Invoice # Well IDN <br />Codes Into B Cash Romhted Serviceuest# <br />EHD 43-06 WELL /PUMP PERMIT <br />430!1'2 <br />