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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 />NUN-KEFUNUABLLE rFKMIT LALL ZVU) UDS•/Oy/ PUK INJI'tL IIUNb <br />CAYIKCJ I T/t:AK I'KUM UAIt I,SUtU <br />JoeADDRE33 <br />CROSS STREET <br />OWNER NAME <br />�J{. I-` • W �� Qn� U n <br />1 .^" '� APN 3 tJ <br />CITY21P <br />4)0d1 ARCEL SIZE 1 �3 <br />( (LC\I <br />LAND USE APPLICATION III 7 <br />PHONE � - 16q - S S'1)'-�/I� � �O <br />C <br />{� d, m e �l o o A <br />OWNER ADDRESS <br />CONTRACTOR <br />[�� <br />1 w' v 0.r\ <br />CrTY/STATE/ZIP -- 4.(-'1 :I ` <br />PHON� 1, �J \ �1 - 4 1 <br />v l "In c , <br />/� `y" <br />CONTRACTOR ADDRESS y q O C- L,\ C C e e •� <br />n <br />D C. CRY/STATE/ZIP <br />SACC 0. m e n! o U <br />S <br />SUBCONTRACTOR <br />PHONE <br />ADDRESS <br />0 C-57 p'C-61 D D-09 O Other. <br />CRY/STATE/ZIP <br />NUMBER �l EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section <br />INTENDED USE 0 Domestic/Private D Irrigation/Agricultural [] Industrial D Water Quality Monitoring ^. Soil Sampling/Characterization <br />D Public Water System <br />If different from Owner: Water SyStOM Name Contact Name or Hnore N,MbSr <br />TYPE OF WORK G New Well D Replacement Well [7 Well Alteration/Modification Other <br />0 Monitoring Well(s) # of wells 0 Soil Boring(s) w of 6odngs Geotechnical a of borings <br />[] Out -Of -Service Well 0 Out -Of -Service Well Renewal [I Cross -Connection Repair <br />F1 New Pumo n Pumn Reolacement n Pumo Repair 0 Raise Well Casino <br />Drilling Method D Mud Rotary O Air Rotary U Auger L] Cable Tool [] Push Point T Other <br />Proposed Well Depth ft Excavation in diameter 0 Open Boftom D Gravel Pack/Gravel Size in diameter <br />D Conductor Casing in diameter / Conductor Casing Depth ft <br />1 <br />Well Casing Diameter in Thickness/Gauge/ASTM Schad 0 Steel 0 Plastic D Stainless Steel Other <br />Grout Seal Depth ft 0 Neat Cement (94 lb beg/5-f0 gal water) D Sand Cement sack mix/7 gal water <br />D Bentonite (20% solids) 0 Other <br />Grout Placement Method 0 Pumped 0 Free Fall 0 Other D Retardant / Accelerator (name) <br />PEDESTAL Installed By 0 Driller 0 Pump Contractor- 0 Other <br />D Concrete Pedestal Dimensions: Width ft Length ft Thick in Christy Box Stove Pipe <br />PUMP 0 Submersible[] Turbine G Other HP Pump Sel ft Standing Water Level It <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 CO NSATION LAWS. <br />I�INIMU/HOUR ADVANCE NOTICER'EQUIRED FOR INSPECTIONS <br />SIGNED !/yt�/ �1i TITLE DAT <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Sol[ Boring Inspection By <br />COMMENTS <br />DEPARTMENT USE ONLY <br />Data <br />Date <br />Data <br />Date <br />J <br />LII <br />L <br />PE SC Received Amount Date Permit/ Invoice # Well IDM <br />Codes Info 8 Cash Remitted Service Re uest # <br />;,3�s 3 Z,-,& 5T 7 3 -01 2-1- 3 zc l - Z co L 14 (�-,o :z c;;i- j <br />EHD 49-08 WELL (PUMP PERMIT <br />8104108 <br />•�'' T <br />Area Employee ID# <br />Sc j <br />' <br />SPECIAL Well Permit <br />/ <br />WAIVER Received <br />Constructed Well Depth <br />ft <br />PE SC Received Amount Date Permit/ Invoice # Well IDM <br />Codes Info 8 Cash Remitted Service Re uest # <br />;,3�s 3 Z,-,& 5T 7 3 -01 2-1- 3 zc l - Z co L 14 (�-,o :z c;;i- j <br />EHD 49-08 WELL (PUMP PERMIT <br />8104108 <br />