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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 CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> t0q4 71 (L M �a l S' M <br /> Joe ADDRESS CITYIZIP Q mS <br /> � Z o <br /> CROSS STREET /nvAPN �✓'~ � PARCEL SIZE LAND USE A/P�PLICATION# �JC� m <br /> OWNER NAME ` PHONEZOTr/ ' gk25-�7I i1�/ y <br /> OWNER ADDRESS CITYISTATEIZI l A �Jr.J��lJJj�� <br /> CONTRACTOR PHONE C?,-15132iV <br /> CONTRACTOR ADDRESS CITYISTATE/ZIPL/J<.A <br /> SUBCONTRACTOR A PHONE D <br /> SUBCONTRACTOR ADDRESS CI /STATE21P <br /> LICENSE C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE <br /> GEOGRAPH CAL INFO MATION: Coordinates X Y Township Range Section <br /> i <br /> INTENDED USE <br /> �Domestjc/Private ElIrrigationlAgricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil SamplinglCharacterization❑ ublic WaterSystem <br /> If different from Owner: Water System Narno Contact Name or Phone Number h_ <br /> TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service ell ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump APumpReplacement ❑ Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary D Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> I <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 lb bag/5-10 gal water) ❑ Sand Cement sackmixl7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant 1 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 Submersible❑ Turbine ❑ Other HPPump 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, 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 /> WORKS OMPENSATION WS. <br /> IN yfl24 OUR ADVANCE NOTIC EQUIFOR INSPECTIONS <br /> SIGNED TITLE DATE <br /> P 1 <br /> I <br /> Is'A1 1 <br /> EA <br /> i <br /> — <br /> D PA TMENT USE NLY <br /> Application Accepted Date Area Employee ID# _ 7vs <br /> Grout Inspection By ate ❑ SPECIAL Well Permit 1 <br /> Pump Inspection By f Date 11 ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> ,.� PE SC Received ChecIT Amount Date PermlV Invoice# Well ID# <br /> Codes info B ash Remitted Service Request# <br /> \` 3v <br /> EHD -O6 WELL[PUMP PERMIT <br /> 91287 7 <br />