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t1p� <br /> WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3RD FL-STOCKTON CA 95202- (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS / 1 v COY/ZIP ��` _ v4/I v <br /> CROSS STREET x E /J � APN O 43 PARCEL SIZE LAND USE APPLICATION# <br /> OWNER NAME �M PHONE <br /> Y?S 6591 <br /> OWNER ADDRESS V" r CITY/STATE/ZIP <br /> CONTRACTOR Q� y' PHONE -3&PL <br /> HONE -3&PL �7 <br /> CONTRACTOR ADDRESS Af(&A 1-12 v CITY/STATE/ZIPA��L <br /> SUBCONTRACTOR r1% PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE -57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE �omestic/Private ❑Irrigation/Agricultural ❑Industrial [3 Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ✓❑Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK.'New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> [3 Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings ❑Geotechnical #of borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> -Nli.jJew Pump ❑Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well DepthL � ft Excavation in diameter ❑Open Bottom ravel Pack/Gravel Size in diameter <br /> ❑Conduc17in <br /> ing in diameter / Conductor Casin Depth / ft <br /> Well Casing Diameter Thickness/Gauge/ASTM Sched 2 ,�, 10a ❑Steel Plastic ❑StainlessSteel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 lb bag/5-10 gal water) Sand Cement t/*..-3 sack mix/7 gal water <br /> ❑Bentonite(20%solids) 13Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method 11:9*umped ❑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 ubmersible ❑Turbine ❑Other HP =;g.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. 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 /> MINI UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED ✓ TITLE V' DATE / -2--K—O <br /> 6 0y <br /> 8 6� <br /> Elf: <br /> / l <br /> I= V _ <br /> t -t - <br /> 8- t <br /> t <br /> N <br /> I�fl-RON.P.1EI,TA <br /> USE ONLY_ <br /> Application Accepted B Date 7i Area Employee ID# G I <br /> Grout Inspection By r. Date �� /�- U3 ❑ SPECIAL Well Permit <br /> Pump Inspection By - Date T�� C/6 El WAIVER Received <br /> Constructed Well Depth It <br /> COMMENTS <br /> - GS <br /> PE SC Received C ec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B ash Remitted Service Request# <br /> 5200 <br /> 4-411-b I oSD 11A 111 <br /> 019 <br /> EHD 43-02-006 WELL PUMP PERMIT <br /> 1/27/2005 <br />