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WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"a 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 <br /> / C CITY/ZIP <br /> S7- <br /> ((; l(�N -a l5 <br /> ...t, v <br /> CROSS STREET f / W� APN�/0 - t 3 PARCEL SIZE ` LAND USE APPP{LIICCA�TTI''ON# <br /> I Q/ <br /> OWNERNAME A PHONE / '"' �� y <br /> OWNER ADDRESS ^V' r CITY/STATE/ZIP <br /> CONTRACTOR CokQ 4" PHONE � /� `� <br /> CONTRACTOR ADDRESS v V l V CITY/STATE/ZIP—.,d/OL�!�/C'�r j <br /> SUBCONTRACTOR W�G7►~ 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 ❑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 /> ❑Monitoring Well(s) p of borings#of wells ❑Soil Boring(s) ❑Geotechnical #of borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> —>iqNew Pump ❑Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point,,/ ❑Other QA <br /> Proposed Well Depth L80 _ft Excavationin diameter ❑Open Bottom �Ciravel Pack/Gravel Size in diameter <br /> ❑Conductor asIng in diameter / Conductor Casint Depth /ft <br /> Well Casing DiameterTin in Thickness/Gauge/ASTM Sched 2—rl�� ❑Steel APlastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 lb bag/5-10 gal water) J.4sand Cement / �12 sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ;1 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 j<5ubmersible ❑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 /> WORKERS COMPENSATION LAWS. <br /> JJ MINI UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED �✓�C'—`9' / ✓"� TITLE DATE (J <br /> 7,—6'-0 <br /> /— 7- <br /> 5 d <br /> - 6 <br /> 8 6� <br /> /l <br /> / 1 <br /> I _ l6 - <br /> 1 -t <br /> S — 1 <br /> t N IR N ETA <br /> 07 <br /> DEPARTMENT USE ONLY <br /> Application Accepted B ` Date—L?,—/ Area Employee ID# <br /> Grout Inspection By `. Date �� /�- U3 ❑ SPECIAL Well Permit <br /> Pump Inspection By Date T�� G!� ❑ WAIVER Received <br /> Constructed Well Depth ft <br /> COMMENTS 5d .� ZPr',� LC �w �7� 1��L/` t <br /> G. <br /> PE SC Received (CffesW Amount Permit/Codes Info B ash Remitted Date Service Request <br /> # Invoice# Well ID# <br /> f6- )n.w 0 SR00 450 9 <br /> EHD 43-02-W6 WELL PUMP PERMIT <br /> 1/27/2005 <br />