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WELL/PUMP PERMIT <br /> SAN.JOAQUIN COUNTY ENVIRONMENTAL.HEALTH DEPARTMENT � OU <br /> 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 /> q-7 T <br /> JOB ADDRESS Gf.s -� CITY/ZIP � [?sal, �5a/ M <br /> J�- / a <br /> CROSS STREET aTTLiI APN [O ? 7d O PARCEL SIZE LAND USE APPLICATION# o <br /> M <br /> M <br /> OWNER NAME GEM{J Sc� co <br /> / PHONE y <br /> OWNER ADDRESS / � CITYISTATEIZIP <br /> CONTRACTOR Oct <br /> PHONE <br /> CONTRACTOR ADDRESS-3 dr <2 r--`- <br /> -- CITY/STATE/ZIP <br /> SUBCONTRACTOR <br /> PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57_ ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> E INTENDED USE omestic(Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: er ys em ame �IIW61 NdMe or Phone Number <br /> TYPE OF WORK New Well. ❑ Replacement Well ❑ Well AlterationlModification ❑ Other <br /> ❑ Monitoring Wells) #of wells ❑ Soil Burin s of borings 9s ❑ Geotechnical #of borings <br /> .0 Out-Of-Service Well ❑ Out-Of-Service Well ReneWal ❑ Cross-Connection Repair <br /> ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method XMud Rotary ❑ Air Rotary ❑ Auger -❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom Gravel Pack/Gravel Siz in diameter \ <br /> ❑ Conductor C-sing in diameter / Conductor Casing Depth_ ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schede❑ Steel lastic Li Stainless Steel ❑ Other <br /> Grout Seal Depth _ft ❑ Neat Cement(94 lb bag/5-90 gal water) ❑ Sand Cement sack mix/7 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 Li Stove pipe ` <br /> PUMP ❑ Submersible❑ Turbine ❑ Other HP Pump Set It 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 /> WORKERS COMPENSATION LAWS. <br /> I UM 24 HOUR ADVANCE NOTICE UIRED FOR INSPECTIONS <br /> SIGNED TITLE DATE <br /> 1 <br /> Al <br /> ------------ <br /> � I <br /> v <br /> N R N U Fry <br /> P R E 7` <br /> ` <br /> DEPARTMENT USE ONLY <br /> Applicati Acce D�/cq�— f�� <br /> ate Area Employee ID <br /> Grout Inspection By Date ❑ SPECIAL Well Permit w <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring I ect)on By Date Constructed Well Depth <br /> COMMENTS O i�/ moi <br /> PE SC Received eck#1 Amount Permit! <br /> Codes Info py Cash Remitted Date Service Re uest# Invoice# Well ID# <br /> 9-c< <br /> a <br /> I <br /> EHD43-06 <br /> 8f04/08 WELL/PUMP PERMIT <br />