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WELL/PUMP PERMIT 1 <br /> 600 EAST MAIN STREET-STOCKTON CA 95202 ' (209)46$'3420 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT EXPIRES 1 YEAR FROM DATE ISSUED � <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS <br /> CITYIZIP S Z"1- <br /> JOB ADDRESSJ� _ ryy LAND USE APPLICATION# N <br /> ` APN ��" 1 h PARCEL SIZE <br /> CROSS STREET PHONE ��'y� <br /> OWNER NAME `-'�'�' 1 <br /> CITYISTATEIZIP ] /1 <br /> OWNER ADDRESS PHONE <br /> CONTRACTOR <br /> � CITYISTATEIZIP <br /> Z _ S f E• <br /> CONTRACTOR ADDRESS E iC� <br /> PHONE ' { <br /> SUBCONTRACTOR �J <br /> CITYISTATE/ZIP <br /> SUBCONTRACTOR ADDRESS r /� _ y <br /> LICENSE 1#C-57 C-61 D-09 Other <br /> NUMBER ca( �13 EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE tw DomesticlPrivate . Irrigation/Agricultural 'Industrial Water Quality Monitoring -. Soil Sampling/Characterization <br /> Public Water Systemon a ame or one um er <br /> If different from Owner: er System Name <br /> TYPE OF WORK New Well ❑ Replacement Well Well Alteration/Modification Other #of borings <br /> Monitoring Well(s) #of wells ,_ Soil Borings) 9o borings Geotechnical <br /> Out-Of-Service Well ❑ Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump f Pump Replacement 7 Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary L, Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth ft Excavation in diameter . Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched - Steel ❑ Plastic ❑ Stainless Steel - Other <br /> Grout Seal Depth ft Neat Cement(94!b ibag/5-10 gal water) C Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped - Free Fall _ Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP 0 Submersible:. Turbine Other HP I Pump Set I4-t`? ft Standing Water Level 1 c 4 _ft <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORD STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIV WIT T CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPEN TION WS. <br /> MINIMUM 2 A VANCE NOTICE REQUIRED FOR IN#)ECTIONS - PLEASE CALL 9 53-7697 <br /> SIGNED TITLE _ [DALE <br /> + I � I I <br /> ILE <br /> DEPARTMENT 7UJSE ONLY <br /> Application Accepted By Date C 61 L� Zai Z Area -/ Employee ID# � <br /> Grout Inspection Date Q SPECIAL Well Permit <br /> Pump Inspectio % Date - 11 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth <br /> COMMENTS <br /> PE SC Received hec Amount Permit! <br /> Codes Info B s Remitted Date Service Request# Invoice# Well ID# <br /> -7 z3 SRoo&s--jfr <br /> EHD 43-06 <br /> 6126109 WELL/Pump PERMIT <br />