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' f <br /> WELL I PUMP PERMIT <br /> SAN JOwQIIIN COUNTY ENVIRONMENTAL HEALTH <br /> DEPARTMENT , <br /> 304 E WE9ER AVE 3""FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> ,� `I <br /> JOB ADDRESS 12p '"` CITYI//ZrIP <br /> f L 1 . <br /> El CROSS STREET 1~� +r APN r <br /> PHONE O <br /> OWNER NAME �•s � -� <br /> CITY/STATEIZIP <br /> OWNER ADDRESS <br /> PHONE <br /> CONTRACTOR111A.Ct1 <br /> CITYISTATEIZIP <br /> CONTRACTOR ADDRESS <br /> PHONE <br /> SUBCONTRACTOR <br /> SUBCONTRACTOR ADDRESS CtTY1S'rATE1ZI P <br /> NUMBER EXPIRATION DATE <br /> LICENSE 13C-57 ❑C-61 ❑D-09 6rOther <br /> �� r <br /> Y Township Range Section <br /> 'GEOGRAPHICAL INFORMATION: Coordinates X - <br /> INTENDED USE mcstic/private ❑Ir. gation/Agricultural ❑Industrial C3 Water Quality Monitoring ❑Soil SamplinglCharacttrization <br /> ❑Public Water System Deer yatcm ame ontact ame or one um r . <br /> 1f difrerene tram Owner: <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Mole ❑other pI'mber of borings <br /> ❑Monitoring Well(s) ❑Soil Borings) <br /> number of wells number of borings ❑Geotechnical <br /> ❑Wcll Destruction ❑Out-Of-Service Well O Out-Of-Scrvice Well Renewal <br /> ❑New Pumumpl.Replacenl ❑PumR Repair ❑Cross-Connection Re air <br /> WELL CONSTRUCTION ❑Cable Tool ❑Push Paint ❑Other <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Gravel Pack 1 Gravel Size in dian""r <br /> Proposed Well Depth tt Excavation in diameter ❑Open Bottom <br /> ❑Conductor Casing in diameter / Conductor Casing Depth A <br /> ❑Steel ❑Plastic D Stainless Steel ❑Other ..— <br /> Well Casing Diameter in Thiekness/GaugdASTM Sehed—� suck mix 17 gal water <br /> ft ❑Neat Cement{9411 hag/3-10 gal water) ❑Sand Cement <br /> Grout Seal Depth _ ❑Specs on File O Specs Submitted <br /> 1, ❑Bentonite(20%solids) ❑Manufacturer Spec%solids %. Name <br /> i Grout Placement Method ❑Pumped ❑Free Fall ❑Other <br /> ❑Retardant/Accelerator(name} <br /> PEDESTAL I,nslalted By ❑Driller ❑Pump Contractor ❑Other - <br /> in ❑Christy Box ❑Stove Pipe <br /> E3 Concrete Pedestai Dimensions: Width tl Length HP�Thickin <br /> Set tt Standing Water Level 7PUMP bmersible O Turbine ❑Other <br /> WELL DESTRUCTION ❑Open Bottom <br /> ❑Gravel Pack O Uncased. ❑Other. ft <br /> Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Pert'orated from fl to <br /> sack+nix 17 gal water ❑Bentonite Pellets <br /> Sealing Material ❑Neat Cement(94 lb berg/3-10 gal water) E3 Sand Cement ❑Specs on File ❑Specs Submittcd <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids /o Name <br /> o- Placement Method ' ❑Pumped ❑Free Fall ❑Other <br /> ❑Complete <br /> ft below rade � to Existing Surface Pad <br /> El Complete with Mushroom Cap g <br /> I HEREBY CERTIFY THAT I HAVPREPARED THIS APPLICATION AND THAT THWORK W <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS, AND RULES AND REGULATIO SE I AAL O CERTIFY LL BE DTHAT My NE IN CR Q CORD EDEL IC SAN <br /> IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPEN ON LAWS. <br /> IMUM 24 HOUR ADVANCE NOTICE R IR7D FOR INSPECTIONS I 21 _U <br /> TITLE DATE <br /> SIGNED <br /> k <br /> 1 <br /> F. vla. N11i NTA.H4 LTH Divi Iii <br />