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WELL 1 PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL? . V1ARTMENT 304 E WEBEk4vet 3""FL-STOCKTON CA 95202 - (209)468-3420 <br /> f <br /> NON-REFUNDABLE PERMIT / CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM/)DATE IfSSUE <br /> JOB ADDRESS /9 8 /F„r <br /> c >.G1/ p�tia CITY/Zip R� <br /> CROSS STREET t=7 �'` `� 1�� APN ��/ CJ�O`�j PARCEL SIZE t j LAND USE APPLICATION# A—C'Ll—`'t u p <br /> OWNER NAME oe vD /V PRONCIZZJ��9 �Il c <br /> OWNER ADDRESS � �� �-f(' T/ h�� _ CITY/STATE/ZIP !t i_ //f�/�L•J �L� � <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITYISTATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEIZIP <br /> LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Runge Section <br /> INTENDED USE ❑Domestic/Private ❑"gation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 0 New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other <br /> borings <br /> ❑Monitoring Well(s) #of wen ❑ <br /> s Soil Boring #of borings ❑ <br /> Boring(s) Geotechnical 4,Q #of <br /> ❑Well Destruction ❑Oat-Of-Service Well ❑Oat-Of-Service Well Ren ewI® 11 - <br /> 7 <br /> ❑New Pum ❑Pum Re lacement ❑Pum Repair Cross-Connection RcI33j <br /> r 6 '/ fJ I <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 1 Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑bleat Cement(941h hag/S-10gal water) ❑Sand Cement .tack mrr/7 gal water � <br /> ❑Bentonite(2011/a solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) I <br /> PEDESTAL Instalied By ❑Driller ❑Pump Contractor ❑Other <br /> ❑Concrete Pedestal Dimensions: Width R Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <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. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS �1 <br /> SIGNED , TITLE�J I�//yLP/G DATE � m <br /> , <br /> TTT <br /> i <br /> i <br /> I TT <br />— - - - - - - - O i C U Y <br /> JC <br /> NV R <br /> //// DEPARTMENT USE ONLY <br /> Application Accepted By / W Date c►7 1 '�Q Area °� Employee ID# �[p <br /> Grout Inspection ByI nn Date ❑ SPECIAL Well Permit <br /> Pump Inspection By ll cy-k 1�L�� Date f1-Z3- OLA ❑ WAIVER Received `+r <br /> Destruction Inspection By Date Constructed Well Depth It <br /> COMMENTS to(L, <br /> tiLu �(, F �_r.u�cel rr cxt S�t�Xi 4-e_ --L) Ct t 4LA <br /> ` - -- <br /> PE SC Received Cbee Amount Date Permit/ Invoice# Well[DO <br /> Codes Info By ash Remitted ' Service Request# <br /> 13.17 0-";"0 ?51 <br /> EHD 43-02-006 <br /> W&G4 WELL PUMP PERMIT <br />