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WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CAL 09 953-76$7 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> m <br /> JOB ADDRESS CITYIZIP <br /> i C D <br /> CROSS STREET v 4 "Tom' APN > L V V'2—PARCEL SIZE 4 1 LAND USE APPLICATION# m <br /> �� <br /> OWNER NAME PHONE <br /> p y� <br /> OWNER ADDRESS41W <br /> CITY/STATEIZIP,-� lCONTRACTOR PHONE � LCONTRACTOR ADD . CITYISTATEIZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEIZIP <br /> LICENSE C-57 ❑ C-61 D D-09 ❑ Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sam piing/Characterization W <br /> ❑ Public Water System <br /> If different from Owner: er em ame ContaCt Name or PnOne Nurnoer <br /> TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> #of borings L1 GeoteChnlcal #of borings <br /> ❑ Monitoring We 11(s) #of wells r] Soil Boring(s) <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pum p-ump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth It Excavation 'in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter I Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft D Neat Cement(941b bag/5-10 gat water) ❑ Sand Cement sack mix17 gal water <br /> ❑ Bentonite(20%solids) . ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant I 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 1(Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level.=ft <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. 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 /> I MI 24 HOUR ADVANCE NOTICE REQUTIED FOR INSPECTIONS <br /> , � <br /> SIGN /L TITLE DATE <br /> IT <br /> II'AlMr-NT <br /> 1 <br /> Ali <br /> ! �� <br /> • � c;ry <br /> I ' <br /> .1Et<4RCnA <br /> f i �i M d''• ?yk -..r7 <br /> {41 y <br /> DEPARTMENT USEO LY �f <br /> I Application Accepted By – Date 10I Area Employee ID# ` <br /> Grout Inspection By Date [I SPECIAL Well Permit <br /> Pump Inspection B Date El WAIVER Received <br /> Soil Boring,---fiction 13y Date Constructed Well Depth ft <br /> ZMENTS lJG/f'�' �77� 71 <br /> SC rReceived Amount Date Permit! invoice# Welf ID# <br /> InfoB Cash RemittedService Re uest#06`� — <S�o 27� 5 <br /> I <br /> WELL IPUMP PERMIT <br /> ' -,BID4108 <br /> --- <br />