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WELL / PUMP PERMIT <br /> F�;AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTNIENT 304 E'WEBER Av.3"n FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES ] YEAR FROM DATE ISSUED <br /> OB ADDRESS tJ�'" CITYIZIP > <br /> k:ROSSSiREET _- - __ APN / 7-1% ]% PARCEL SIZE <br /> WNER NAME i P}aIO�N1E 44 /I� <br /> �1 CITYISTATE/ZIP /�/w C.2 PA <br /> � y�D('r` <br /> FWNERADDRESS ,l�L�`3 Y4- r'/ ` /z/ - - '� -- / <br /> /G /// .T.4 7i4P)IONE / �I� 2in <br /> rONTRACTOR <br /> ONTRACTOR ADDRESS f CITYlSTATEIZIP <br /> SUBCONTRACTOR - + iZ�f y�7 /1 rL—! j -- P/IJONNF �—%� � <br /> 71, <br /> UB('ONTRACTORADDRESS '' , �""" eZ� CITY/STATE/ZIP <br /> ! <br /> rj� <br /> �/ff{��C7- 1koz <br /> I LICENtiF. .. 57 61 ❑D-09 ❑Other NUMBER KI IIM EXPIRATION DATE I <br /> EOGRAPMCAL INFORMATION; Coordinates X Y Township Range Section <br /> NTEND£D USE vmesticlPrivate ❑]rrtgationlAgricultural ❑industrial ❑Water Quality Monitoring 0 Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from wrier: Water ysicm Name ontact Name or Phone Number <br /> ai PE OF WORK Jew Well ❑Replacement Well ©Well AlterasionlModification ❑Test Hole C7 Other <br /> number ofwelks number of borings numheroFhorings <br /> ❑Monitoring Wel(s) ❑Soi1 Bormg(s) ❑Geotechnical <br /> ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal <br /> F <br /> ew Purnp ❑Pump Replacement ❑Pump Re air 0 Cross-Connection Repair <br /> WELL CONSTRUCTION t <br /> Drilling Method ud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point 0 Other <br /> Proposed Well Depth .Qr n ExcavationZA? in diameter ❑Open Bottom ravel Pack I Gravel Size Xin diameter <br /> ❑Conductor Casing in diameter / Conducto�r Casing Depth tt <br /> Depth <br /> Well Casing Diameter in /Thickness/Gauge/ASTM Sched�� L[s� ❑Steel 471astic 0 Stainless Steel ❑Other <br /> Grout Seal Depth + tt ❑Neat Cement(94 ih hag/S-!0 gal waler) ❑Sand Cement sack mtx/7 gal water <br /> ❑Bentonite(20%solids) 'l-Imanufacturer Spec%solids % Name ❑Specs on File 0 Specs Submitted <br /> Grnut Placement Method umpcd ❑Free Fall ❑Olher ❑Retardant I Accelerator(name) <br /> EUESTAL Installed BY ❑Driller ❑Pump Contractor ther Y _ � el 4� <br /> ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in Q Christy Box Q Stove Pipe <br /> YUMp ubmersible ❑Turbine ❑Other HP_ Pump Set ti Standing Water Level ti <br /> TELL DESTRUCTION ❑Open Bottom 0 Gravel Pack ❑Uncased ❑Other <br /> ! Well Diameter in Total Depth ft Depth to Water R ❑Casing to be Perforated From ft to ti <br /> 4 Scaling Material ❑Neat Cement(94 lh hub/5-10 gal water) ❑Sand Cement sack mix 17 gal water Q Bentonite Pellets <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> FPlacement Method ❑Pumped ❑Free Fall ❑Other <br /> 11 ❑Complete with Mushroom Cap R below grade ❑Complete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> r OAQUI <br /> N COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT NTY REQUIRED LICENSE IS <br /> -URRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> I YORKERS COMPENSATION LAWS. <br /> s MI I HQ DVANCE NOTICE REQUIRED FOR INSPECTIONS— PLEASE CALL (209)953-7697 <br /> 1GNED TITLE _ ��� �� DATE <br /> �e <br /> l0 <br /> d <br /> WA I <br /> / <br />