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WELL/PUMP PERMIT <br /> AN�crn IN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT <br /> �J rCALLL 2109 953-7697 FOR INSPECTIONS EXPIRES 1�YEAR <br /> 7FROM DATE ISSUED <br /> JOB ADDRESS 1�r+ LTJ t y� i f /{(' J ✓� / --- N <br /> 11�c�[ m <br /> CITYRIP a <br /> 4/ a �2 <br /> CROSS STREET ryQ/j� j��}� APN Z�,J +�Ai- " I[I PARCEL SIZE LAND USE <br /> �JAPPLICATION <br /> �#J m <br /> OWNER NAME 1 t=//IL 1 fr /� I n PHONE b 1- —1A L- <br /> OWNER ADDRESS 424 O 1/C�Cr 6+ i.l 'r _ _ CITYISTATEIZIP r <br /> CONTRACTOR M A 1� � PHONE <br /> CONTRACTOR ADDRESS F5-3 FJ 6' 6�Q(�1 ►�-+rel,r . CITYISTATEIZIP �owDf) . Gp• F� <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEIZIP <br /> LICENSE �(C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 4 6Zq EXPIRATION DATE �� ✓ <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner. Water System Name L;GntaCt Name or Phone-kpmber <br /> TYPE OF WORK ❑ New Well ! eplacement Well ❑ Well Alteration/Mod'(cation KOOther 1 <br /> Li Monitoring ells) #of wells ❑ Soil Boring(s) #of borings Li Geotechnical #of borings <br /> C1 Out-Of-Service Well ❑ Out-Of-Service Well Renewa Con nectiorLRepair <br /> ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rota ❑ Air Rotary ❑ Auger ❑ Cable Too] ❑ Push Point ❑ Other <br /> Proposed Well Depth U5 It Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> ❑ n cto asing in diameter / Conductor Casing Depth ft <br /> Well Casing Diame ti I Thickness/Gauge/ASTM Sched ❑ Steel (Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal th ft ❑ Neat Cement(94 lb bag/5-10 gal water) )(Sand Cement I D%,J sack mix(7 gal water <br /> -mite G%solids) ❑ Other <br /> Grout Placement Method V6 Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal Dimensions:Width It Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible❑ Turbine J4 Other HP Pump Set ft 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. 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 /> WORKERS COMPENSATION LAWS. <br /> 11 <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209) 9 JVr <br /> SIGNED TITLE�� (:�{4A�7 " DATE �it,_ <br /> VA 1 41 <br /> N <br /> C <br /> E t <br /> F I- <br /> 2.51rj:L <br /> SA <br /> PH <br /> r <br /> L <br /> e <br /> I _ - ---- <br /> ` `�- s -D PA TMENT U E ONLY <br /> Application Accepted Date 11o, Area Employee ID# (ROT <br /> Grout Inspection By Date ` ❑ SPECIAL Well Permit G�1, <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS�fiYlli �s�X1 /I --- <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> M <br /> EHD 43-06 <br /> �y O� WELL(PUMP PERMIT <br /> 6126!09 <br />