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WELL / PUMP PERMIT n; <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEIARTMENT 304 E WEBER i,,.c 3"O FL-STOCKTON CA 95102 <br /> - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 109 953-7697 FOR INSPECTIONS EXPIRES l YEAR FROM DATE ISSUED <br /> v <br /> JOB ADDRESS CITY/ZIP � <br /> i t , a <br /> CROSS STREET APN {—C.�® o <br /> _ 1 <br /> is PARCEL.SIZE�LAND USE APPLICATION# � <br /> t OWNER NAME C PHONE <br /> III OWNER ADDRESS CITY/STATE/ZI <br /> I � <br /> CONTRACTOR WryV <br /> PHONE - <br /> CONTRACTOR ADDRESS CITYISTATEIZI <br /> { <br /> SUBCONTRACTOR <br /> PHONE <br /> SUBCONTRACTOR ADDRESSj� ITY/STATE/ZIP <br /> LICENSE ❑C-57 C-61 ❑D-0911 ❑Other NUMBE <br /> EXPIRATION DATE 'r <br /> GEOGRAPHICAL INFORMATION: Coordinates1 X Y Township Range Section <br /> INTENDED USE mestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner; stet ystem ame Connie, Name.,rnone r.4um er ! <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole El Other 1 <br /> CI Monitoring We]l(s) !#of wells ❑Soil Boring(s) #of borings ❑Geotechnical #of borings <br /> ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of Service Well Renewal <br /> ❑New Pumn Pump Replacement ❑Pump Repair ❑Cross-Connection REEir <br /> WELL CONSTRUCTION i <br /> Drilling Method ❑Mud Rotary C3 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 fi <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth R a Neat Cement(941h hag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <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 Cl Turbine 0 Other HP Pump SctM ft Standing Water Level ft <br /> ilk i <br /> I HEREBY CERTIFY THAT 1 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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. I <br /> l <br /> 9iM 1 H R ADVANCE NOT1C EQU1 ED FOR INSPECTIONS <br /> SIGNED TITLE DATE <br /> i <br /> 'AN <br /> JC q <br /> rN R M N AL <br /> T <br /> DEPARTMENT USE ONLY ` <br /> Application Accepted By f ll<r t---------- Date l �(-� Area '28inployee ID#' <br /> GroutInspection Date 13 SPECIAL Well Permit II <br /> Pump Inspecti n , Dat /� � ci ❑ WAIVER Received <br /> Destruction Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> i <br /> PE SC Received Ch Amount Permit) <br /> Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# <br /> �a txJ D '_59 `i c- <br /> EHD 43.02.606 WELL PUMP PERMIT <br /> s16l64 <br />