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WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 95202 -(209)469-3420 <br /> NON-REFUNDABLE PERMIT G��{,,___CA 2H)9�/5/�3-7697 FOR INSPECTIONS ----EXPIRES.1 YEA FR[O�M DATE TISSUED y <br /> J�T !a) s- (JrJi(.C�MA.L-[ IAV CITYIZIP <br /> JOB ADDRESS �J D <br /> CROSS STREET �3Z _ APN �S- -'"/PARCEL SIZE`�—e LAND USE APPLICATION M _ A <br /> OWNER NAME WUC <br /> OWNER ADDRESS CITYISTATEIZIP <br /> l'/•� �a/Z PHON G�� <br /> CONTRACTOR !� <br /> CONTRACTOR ADDRESS (301c CITYrSTATE/ZP &1 00 ,CA- ,r4 <br /> 5(.q <br /> SUBCONTRACTOR __ _ PHONE <br /> SUBCONTRACTOR ADDRESS __ CITYISTATEIZIPP <br /> LICENSE NFC-57 C-61 D-09 Other NUMBER S*✓ EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates Y Township_ Range Section_ <br /> INTENDED USE Womestic/Private 1 Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization I <br /> I' Public Water System <br /> if ElSurent from -..1� "1�'�e---- <br /> TYPE OF WORK New Well C Replacement Wen Well Alteration/Modification D Other <br /> - Monitoring Well(s)— N of wells Soil Bonng(s) e of Don rip � Geotechnical a of DonnG s <br /> Out-Of-Ser�Well ' Oul-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump, a Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth_n Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter ^ <br /> i Conductor Casing in diameter / Conductor Casing Depth it f <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel , Other <br /> Grout Seal Depth ft I'.Neat Cement(94 lb bag/5-10 gal water) Sand Cement_ sack mix/7 gal water <br /> Bentonite(20%Solids; Other <br /> Grout Placement Method Pumped Free Fell Other =_ Retardant/Accelerator(name) <br /> PEDESTAL Installed By : Dnller Pump Contractor Other ' <br /> Concrete Pedestal Dimensions Width it Length It Thick in Christy Bok -,Stove Pipe <br /> I <br /> PUMP -%Cubmersiblef Turbine i Other HP Pump Set fi Standing Water Level it <br /> I 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 /> (;URRLNT A1r0 ACTIVE WITH rHE CALIFORNIA CONTRACTORS STATE LICENSE BOARD ANL) fHAf I-AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> N1Nl�'jj'��I�'\4}HOUR <br /> _ ADVANCE NOTICE <br /> y�REQUIRED <br /> �FOR IINNSPECTIONS <br /> SIGNED 1/ TITLE DATE ` <br /> 1 <br /> 7 <br /> 1 <br /> AYMENr <br /> ECEIVED <br /> tNVOENT <br /> OAQUIN COUNTY <br /> T}{Rp PAATMENT <br /> L D E P A R T M E N T U E ONLY <br /> Application Accepted By Date 2X 1 � Area Employee IDN 4fz f 5 <br /> C <br /> Grout Inspection By D to SPECIAL Well Permit <br /> Pump In cfion By Date Z3 WAIVER Received <br /> Sat Borin rcUon BY. Date i Constructed Well Depth ft <br /> COMMENT <br /> PE SC Received he Amount Permit/ <br /> Codas Info B ash Remitted Date Service Re ue5t N Invoice N Well IDY <br /> �13s; cs� 323 <br /> 1'5a,-o -7 <br /> EHD�7-0a WELL MUMP PERMIT <br />