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WELL 1 PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH G._ nRTMENT 304 E WEBER—,7E 3"°FL-STOCKTON CA 95202 - (209)468-3424 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> f}p r ' <br /> JOB ADDRESS �a3— f u �� +CITY/ZIP <br /> CROSS STREETA APN � 3. --CEL SIZE LAND USE APPLICATION# <br /> � rzi <br /> OWNER NAME I ._ [[ G� S�� __ PHONE ^� <br /> OWNERADDRESS r+T� CITY/STATE/ZIP <br /> CONTRACTORi PHONE <br /> CONTRACTOR ADDRESS l CITY/STATE/ZIP Mep �pj <br /> SUBCONTRACTOR I <br /> PHONE <br /> SUBCONTRACTOR ADDRESS <br /> CITY/STATE/ZIP <br /> LICENSE, C-$7 ❑C-61 ❑D-09 ❑Other NUMBE EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section �J <br /> INTENDED USE Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner Water System ame onract Nameor Phone Number <br /> TYPE OF WORK y�w Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole D Other <br /> I <br /> ❑Monitoring Wells) #of wells ❑Soil Borin s N of borings oborin gs <br /> g( ) ❑Geotechnical N f b <br /> ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal C <br /> ❑Naw Pum ❑Pum Re ]acement ❑Pum Re air El Cross-Connection Repair r <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth _ft Excavation diameter ❑Open Bottom Grave]Pack/Gravel Size in diameter <br /> ❑Conductor sing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schede_ ❑Steel lastic ❑Stainless Steel Cl Other <br /> Grout Seal Depth ft ❑Neat Cement(941h hag/S-10gal water) ❑Sand emertt sack mix/7 gal water <br /> $Bentonite(20%solids) ❑Manufacturer Spec%Solids % Name L ❑Specs onFile ❑Specs Submitted <br /> Grout Placement MethodPumped ❑Free Fall ❑Other -- 11 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller �kn—ump Contractor ❑Other <br /> ❑Concrete Pedestal Dimensions: Width R Length ft Thick in ❑Christy Sox ❑Stove.Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN j <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 /> ,^ MINIM iV�.24 HOUR ADVANCE NOTIC REQU7"D FOR INSPECTIONS <br /> SIGNEDL✓ ' C � rTITLE I DATE <br /> FF <br /> 1 <br /> i <br /> - I <br /> I <br /> i <br /> I <br /> t l <br /> twig 9v <br /> i <br /> 1 r C <br /> I <br /> SA JA ! U <br /> f—ZI TA <br /> D A RTM E NT USE ONLY <br /> Application Accepted By Date Area Employee IDi�l <br /> GroutInspection By - Date l/ �] AL Permit <br /> WEII Perlt <br /> Pump inspection By Date ❑ WAIVER Received <br /> Destruction Inspect' n By Date Constructed Well Depth ft <br /> COMM T -- <br /> We <br /> PE SC Received Check#1 Amount Permit! <br /> Codes Info B ash Remitted Date Invuic e111D <br /> Service Request# <br /> ag S` o <br /> EH D 43-02-006 <br /> 916104 WELL PUMP PERMIT <br />