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+� '�LTAJWELL / PUMP PERNIIT � // .7 <br /> 17 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH RTMENT 304 E WFBER'R4E Sae FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-R ;FUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 44'/A2Aa4 Jl/1 ' CITY/ZIP A C41m aL q--7 e z V <br /> a <br /> CROSS STREET APN �VV� ( '1-1 3 LAND USE APPLICATION# C <br /> S1513�-I�'I VI�[�l� PARCEL SIZE 1U✓c /. P <br /> OWNER NAME PHONE m <br /> OWNER ADDRESS CITY/STATE/ZIP cif <br /> CONTRACTOR PHONE - <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP V, <br /> -0 /' <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP `''� <br /> LICENSE -57 13C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE/—3L—6 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Cha acterization <br /> ❑Public Water System <br /> Ii'diff.rentfiromObvom Water Symat N.me Correct Nam or Phone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other <br /> ❑Monitoring Well(s) #ofwells ❑Soil Boring(s) #ofborinya ❑Geotechnical 4o boring <br /> ❑Well Destruction ❑Out-Of-Service Well ❑Ou f-Service Well Renewal <br /> ❑New Pum ❑Pum Replacement ❑Pum Repair nnectio R it <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 lb hag/5-10 gal wafer) ❑Sand Cement sack mix/7 gal water -� <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted v <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) --� <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other <br /> ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove.Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set It Standing Water Level It <br /> 1 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. I 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 /> MINI 24=OUR NOTICE QUI ED FOR INSPECTIONS <br /> SIGNED TITLE DATE <br /> r <br /> �A T <br /> E M _ <br /> D ARTMENT USE ONL <br /> Application Accepted By Date�� Area 2-If Employee ID# 53 l(moi <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By 7-- Date ❑ WAIVER Received <br /> Destruction Inspection By /^ Date Constructed Well Depth ft <br /> COMMENTS �T7 t/ Ll 'V <br /> PE SC Received Check#/' Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Re uest# <br /> EHD 43-02-W WELL PUMP PERMIT <br /> a1N04 <br />