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. WELL/PUMP PERMIT <br /> .SAN JOAOt1IN COUNTY ENVIRONMENTAL HEALTH DEPARTFIENT 3174 E WEBER AVE 3"Ft.-STOCKTON CA 952112 - (269)468-34211 <br /> ..1ON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS. EXPIRES I YEAR FROM DATE ISSUED <br /> l/ _ I M <br /> JOB AUDRESS I. - CITY]/ZiIP' D <br /> CROSS STREET ' e APN {_JQ /y-ty(/1 - �(y PARCEL SIZE <br /> v <br /> (/ x <br /> r OWNERN'AHE \� PHONE <br /> /1/� Q( d <br /> OWNER ADDRESS 4 rJ� �� CITYISt'AT"rPA( 4of ),) <br /> CONTRACTOR 1 PHONE <br /> TR <br /> CONTRACTOR ADDRESS CITYlSTATE/ZIP <br /> SLBCONTRACTOR PHONE <br /> SUBCONTRAL ToR ADDRCSS CTTYISTATEIZIP _ <br /> LICENSE 657 C-6i ❑D-09 ❑Other NUMBER:) 3$3- EXPIRATION DATE - <br /> GEOGRAPHICAL INFORMATION; Coordinates X Y Township Range Section <br /> INTENDED USE DOmesticftn ale ❑IrrigalionlAgricultural ❑Industria! ❑Water Quality Monitoring ❑Soil Sampling/Characterization } <br /> ❑Public Watcr System <br /> tfdiff—I from6.— Wt.,Sys.em N.rw .onun ame or am r <br /> l <br /> TYPE OF WORN New Well ❑Replacement Well Q Well AlterationfModification ❑Test Hole 0 Other <br /> ❑Monitoring Well(s)_- nuvhcrufwdlr ❑Soil Boring(s) r' bo,orbonngS ❑Geotechnical oumberottronrip <br /> ❑Well Destruction ❑0ut-0FService WeII ❑Out-Of-Scrvice Well Renewal <br /> 11rNew Pum ❑Pump ft lacement ❑Pump Repair 0 Cross-Connection Repair <br /> WELL CONSTRL ION <br /> Drilling Me"., ud Rotary ❑Air Rotary ❑Augej� ❑Cabic Tool ❑Push Point��d Other <br /> Proposed Well Depth x2/20 R En 1xcavatio ,__ in diameter ❑Open Bottom [&(5 avcl Pack/Gravel Size�in diameter <br /> C7 Cnnduc or Casing in diamcler / Conductor Cam Depth It <br /> Well Casing Diamtte[ ( in ThicknesslGaugelASTM Sched d5 (1�7R ❑Stttl esGc ❑Stainless Steel ❑Other <br /> Grout Seal Depth IW._ tt ❑Neat Cement 04 1b hug/340 gat water) nd Ce nl .rack mix 17 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name MV-—e ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method )lumped ❑Free Fall ❑Other ❑Rerardatlt 1 Accele Ira or(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other <br /> Concrete Pedestal Dimensions: Width R Length It Thick in ❑Christy Box ❑Stove Pipe W VW <br /> POMP Submersible ❑Turbine ❑Other HP Pump Set R Standing Water Level R <br /> WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other <br /> Well Diamete in Total Depth f1 Depth to Water fl ❑Casing to be Perforated from R to tt <br /> Scaling Material ❑Neat Cement(941h hag/3-10 gal water) ❑Sand Cement .ruck mix/7 gal water ❑Bentonite Pellets <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Placement Method ❑Pumped ❑Free Fall ❑Other <br /> ❑Complete with Mushroom Cap R below grade ❑Complete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL HE 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 /> MININW 2 HOU9.413VANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)95- 7697 <br /> SIGNED TITLEDATE <br /> lilt <br /> SAN A U'. COUN <br /> iH k!7!Di Ijl <br /> l <br /> or V <br /> YP <br /> ARTMENT UON �1 <br /> Application Accepted By ate V 31 Area ��-/i� Employee[DO <br /> Grout Inspection Date © 4ECIAALL Well Permit <br /> Pump Inmpeeti By Dam ❑ WAIVER Received <br /> Destruction Inspection By j�/i1 C�a7id a Dat ons I tted Well Depth R� <br /> COMMENTS- - <br /> PE Sc Received Chec Amount Date erm vuicrsJlr <br /> Codes Info B Cash Remitted Service R neat <br /> 7 37�— z -; 0 ' <br /> D 5ZRo m <br />