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WELL 1 PUMP PERMIT <br /> 11N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3m FL-STOCKTON CA 95202 - (209)468-3420 <br /> ....,FUNDABLE PERMIT CALL 209)953-7697 FOR INNPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �.yl`�rliC1►I Y+ CAm pA 'tor- CtTY/TdP <br /> CROSS STREET APN S'O �[ ^�I ±PARCEL SIZE � 0? <br /> OWNER NAME �1,�iQeG PHONE <br /> OWNERADDRESS ZLI. .7 �. F� .fN4^�0L1r". CtTY/STATEMP T i.C,� <br /> �, , <br /> CONTRACTOR PHONE <br /> GONTRACTORADDRt Crrv►STATrMp 'Tt�,Ir twf <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE O C-57 O C-61 O D-09 ITOther \ NUMBER EXPIRATION DATE oS <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private O Irrigation/Agricultural O Industrial 13 Water Quality Monitoring 0 Soil Sampiing/Charecterization <br /> O Public Water S sunt <br /> Ifdiffemufmm Ownw. waterm NWM Ciontako NNWarPFziFN—UMW <br /> TYPE OF WORK O New WeII M Replacement Well O Well Alteration/Modification ' O Test Hole 0 Other <br /> O Monitoring Well(s) numbarofwetlr 0 Soil Boring(s) twmberofbodaip ❑Geotechnical membrrofborinp <br /> W11 Destruction 0 Out-Of-Service Well 0 Out-OP-Service Well Renewal <br /> Pump ❑Pump Replacement Q Pum R it O Cross-Connection Repair <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool 0 Push Point 0 Other <br /> Proposed Well Depth ft Excavation in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size in diameter <br /> O Conductor Casing in diameter / Conductor Casing Depth _ f1 <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched U Steel C Plastic O Stainless Steel O Other <br /> Grout Seal Depth ft O Nat Cement(941b bag/3-10 gal wwrrr) D Sand Cement suck mix/7 gal water <br /> O Bentonite(20%solids) 0 Manufacturer Spec%solids % Name 0 Specs on File O Specs Submitted <br /> Grout Placement Method 0 Pumped 0 Free Fall Cl!Other O Retardant/Accelerator(name) <br /> PEDESTAL Ingalled By 0 Driller 0 Pump Contractor 0 Other <br /> 0 Concrete Pedestal Dimensions: Width ft Length ft Thick in 0 Christy Box 0 Stove Pipe <br /> PUMP Blubmersible 0 Turbine O Other RP Ij_ Pump Sete ft Standing Water Level ►'3> it <br /> WELL DESTRUCTION 0 Open Bottom 0 Gravel Pack 0 Uncased 0 Other <br /> Well Diameter in Total Depth ft Depth to Water_ft 0 Caging to be Perforated from ft to ft <br /> Sealing Material 0 Neat Cement(941b bag/3-10 gal wwfer) 0 Sand Cement sack mix/7 gal water Cl Bentonite Pellets <br /> 13 Bentonite(20%solids) 0 Manuliwtumr Spee%solide�% Name 0 Specs on File 0 Specs Submitted <br /> Placement Method 0 Pumped 0 Free Fall O Other <br /> D Complete with Mushroom Cop ft below grade 0 Complete to Existing Surfaee Pad <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, STA'L'E 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 UR AD N TICE REQUIRED FOR.INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE ���-.� DATE <br /> `1 <br /> O Q <br />