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a�� q V—41,!T!"ek _z,, <br /> WELL MP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3-FL-STOCKTON CA 9520 9)468-3420 <br /> NON-REFUNDABLE PERMIT 'CALL(209«ys9-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROMU TE ISSUED <br /> JOB ADDRESS y/�/, z ( &X <br /> CITY/ZIP_ <br /> CROSS STREET C.. APN b f 31 J-O&X !�e D � � <br /> PARCEL SIZE LAND USE A PLICATION# <br /> OWNER NAME Of- PHONE <br /> III OIANERADDRESS -Ll CITYISTATrJZIP — SCANNED <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITYISTATElZ1P <br /> SUBCONTRACTOR � G / ( / ! I1L1 PHONOW2�O Zr <br /> SUBCONTRACTOR ADDRESS CITYISTATE/ZH` <br /> LICENSE C-57 C-61 ❑D-09 ❑Other NUMBER ExPIRATION DATE (� <br /> hEI GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />{ INTENDED USE Domestic/Private ❑Irrigation/Agricultumi ❑Industrial ❑Water Quality Monitoring ❑Soil SamplinglCharacierizetion <br /> ❑Public Water System <br /> Ifdiff—At fmm Owner. W.Wr Systc. ame marl ameor Phone um cr <br /> i TYPE OF WORK New Well ❑Replacement Well ❑Well Altetation/Modification ❑Other (� <br /> ❑MonitoringWell(s) #ofwclls M Soil Boring(s) 0ofbodi,p ❑Geotechnical 9ofboring <br /> ❑Out-Of-Service Well ❑Out-Of--Service Well Renewal ❑Cross-Connection Repair <br /> JX`New Pump ❑Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method;(Mud Rotary�hy ❑Air Rotary ❑Auger 13 Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth G ft Excavation 41 diameter Cl Open Bottom Gravel Pack/Gravel Size in diameter <br /> ❑Conductor aging in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter �inickncss/Gaugc/ASTM Scbed ❑Steel Q Plastic ❑Stainless Steel ❑Other <br /> Grout Seal DepthNeat Cement(9416 bog15-10ga1ware,)• Sand Cemel zo, _3 sack mix 17 gal water <br /> ❑Bentonite(20Manufacturer Spec%solids % Name Y ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL inslatled By #Driller ❑Pump Contractor ❑ Other <br /> Concrete Pedestal Dimensions:Width ft Length 6 1t Thiok in ❑Christy Box ❑Slove Pipe <br /> PUMP Submersible 0 Turbine ❑Other HP=Pump Set ti Standing Water Level it <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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE DATE <br /> s <br /> 1 <br /> 1 <br /> � L Q <br /> ti <br /> DEPARTMENT USE ONLY <br /> /7 <br /> Application Accept y .,i — Date 'S -6 1 'Q Area Employee lD# <br /> Groin Inspect Date 13SPECIAL Well Permit <br /> Pump Inspection By �7e- Date 13WAIVER Received <br /> Constructed Well Depth o5/Uf r It <br /> COMMENTS (✓L 6 t-.V! x) r0.E J �' <br /> PE Sc ReceivedAmount Date Permit/ Invoice# W01 IDA <br /> Codes Info By <br /> =51 <br /> Remitted Service Request# <br /> .f3•(:(; I� _ 2 3 1 UU <br /> �f3. (7SJ 5'ut`J <br /> EHD 43-02-006 WELL PUMP PERMIT <br /> 1/2712WS <br />