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WELL/ PUMP PERMIT <br /> IN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"n FL-STOCKTON CA 95202 - (209)468-3420 <br /> /WN <br /> FUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTION'S EXPIRES 1 YEAR FROM DATE ISSUED <br /> SS �Lx] L Cr— "' I CITYIZIP� iI �'� <br /> m <br /> / r� r � <br /> EET ^� APIr"'/,6eq—Sr T�'— tl <br /> PARCEL <br /> /SIZE <br /> ME �7 GIrPi PHONE � �j �� y <br /> DRESS ClTY1STATEIZIP C ��� <br /> CONTRACTOR �/J//f Sf��//J 1'tGL�I _ _ PHONE r� <br /> CONTRACTOR ADDRESS i , ✓s- I�r CITYISTATE/ZIP <br /> SUBCONTRACTOR ( PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATE/ZIP D <br /> LICENSE 57 0'C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE omesticlPrivate ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water m S ste <br /> If different From Owner: ater ystem oma ontact ame or Plione NUm er <br /> TYPE OF WORK ew Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other — <br /> number of wells number of borings n <br /> ❑Monitoring Well(s) []Soil Boring(s) ❑Geotechnical�Ec�� <br /> ❑Well Destruction ❑put-Of-Service Well ❑Out-Of-Seryice Well Renewal <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Crass-Connection Repair ni)11 <br /> _:SVELL-CONSTRUCT �rr.�! r <br /> Drilling Method MuRotary ❑Air R' int ❑Other <br /> d ��pp, <br /> Proposed Well Depth ft L/6/4# 5 /-- P-11� <br /> 71 C— ❑Gravel Pack/Grave]SttRBNMI11i6shteter <br /> ❑Conductor Casing _ft HEALTH DEPARTMENT <br /> Well Casing Diameter to Thicknes a�Q�.p� r ❑Stainless Steel ❑Other <br /> Crout Seal De th ft d r/f fent ,yuck mix/7 gal water <br /> Bentonite(20%solids) 1 /], � ! ❑Specs on File ❑Specs Submitted <br /> { ��lr <br /> Grout Placement Method umped 13 Fret irator(name) <br /> PEDESTAL Installed By ❑Drill <br /> ❑Concrete Pedestal Dimen� in ❑Christy Box ❑Stove Pipe <br /> Pump ❑Submersible ❑Tur6 ft Standing Water level ft <br /> WELL DESTRUCTION ❑Open Bottom I <br /> Well Diameter in Total g to be Perforated from ft to ft <br /> Sealing Material ❑Neat Cement(94Th hu' p Tal water ❑Bentonite Pellets <br /> ❑Bentonite(20%solids) ❑ `( �9 t 1O l�s� ❑Specs on File ❑Specs Submitted <br /> Placement Method ❑Pumped ❑1 �T <br /> 1:1Complete with Mushroom Capi 1 Existing Surface Pad <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED H BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS AND R D REGULATIONS. 1 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 /> MINIMUM 24 HOUR ADVANCE N REQUIRED FOR INIPECTIONS—PLEASE CALL(209)953-7697�y <br /> SIGNED r TITLE DATE P <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Area Employee IDN <br /> Grout Inspection By 1 Date ❑ SPECIAL Well Permit <br /> Pump Inspection By w Date ❑ WAIVER Received <br /> Destruction Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> 1 PE SC Received Check#1 Amount Date Permit/ Invoice# Well ID# <br /> Codes Into B Cash Remitted Service Request# <br /> 1 <br /> 7 43-02-006 MASTER WATER WELL PERMIT <br /> i '2002 <br />