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WELUPUMP PERMIT <br /> F'AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 95202- f109)466.3420 <br /> ION-REFUNDABLE PERMIT CALL 209 L 1'697 FOR INSPECTIONS EXPIRES 1 YEAR FROK �rE ISSUED <br /> / fA <br /> Jog ADDRESS / �T % �4 - - — CITYIZIP e n . <br /> I o <br /> •ROSSSTREET 4'R a e� LV© APN Z��PARCEL SIZE LAND USE APPLICATION# m <br /> y <br /> OWNER NAME rF J2 t ._—��!�7 S L L l_ - - PHONE N . <br /> OWNER ADDRESS - CITYISTATE/ZIP <br /> ;ONTRACTORR131-SDVTy�j) ���� �-Sf a� PHONE 'Z7`�Q <br /> �;pNTRACTOR ADDRESS E � �r. CITYISTATEIZiP 5 7 <br /> SUBCONTRACTOR PHONE <br /> .UBCONTRACTOR ADDRESS CITYISTATFJZIP <br /> LICENSE n C-57C-61 D 0-09 n Other NUMBER Q EXPIRATUZ <br /> ION DATE <br /> EOGWHICAL INFORMATION: Coordinates X Y TownshipRange Section <br /> yTENDED USE ADomesliOPrivate C IrdgationlAgricuitural 4 Industrial D Water Quality Monitoring ❑Soil Sampling/Characterization <br /> t 0 Public Water System <br /> If different from Owner, Water System Name Uontact Name or Phone Numoer <br /> rE OF WORK 0 New Well C Replacement Well 71 Well AlterationlModifcation 0 Other <br /> - #of boriigs #of borings <br /> C Monitoring Well(s) #of wells 0 Soll BQring(s) n Geotechnical <br /> .13 Out-Of-Service Well I ❑Out-Of-Service Well Renewal ❑Gross-Connection Repair <br /> New Pump C Pump Replacement D Pump Repair D Raise Well Casing <br /> WELL CONSTRUCTION - <br /> Drilling Method C Mud Rotary 0 Air Rotary G Auger D Cable Tool C Push Point C Other <br /> i roposed Well Depth ft Excavation in diameter D Open Bottom 0 Gravel PackJGravel Size in diameter <br /> C Conductor Casing in diameter I Conductor Casing Depth It <br /> Well Casing Diameter&in Thickness(GaugelASTM Sched 0 Steel 19,Plastic C Stainless Steel 11 Other <br /> Grout Seal Depth ft O Neat Cement(94 lb bag15.10 gal water) ❑Sand Cement sack mixl7 gal water <br /> j C Bentonite(20%solids) Q Other <br /> Grout Placement Method D Pumped C Free Fall D Other ❑Retardant I Accelerator(name) <br /> PEDESTAL Installed By D Driller n Pump Contractor 0 Other <br /> C Concrete Pedestal Dimensions:Width ft Length ft Thick in 0 Christy Box 0 Stove Pipe <br /> 'uMP SubmersiblsC Turbine ❑Other HP Pump Set ft Standing Water Levei ft <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 /> URRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> iNORKERS COMPENSATION LAWS. t <br /> tI +, MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED I, TITLE 11Y1 Q7 010 ._ DATE Q <br /> i <br /> FEI—l' <br /> P iIke I <br /> 74 <br /> tL�Uu <br /> F <br /> Fj <br /> 5 � O L <br /> p TS E <br /> kD A TMENT USE 9N1LY <br /> Application Accepted B e Date 'i Area Employee ID#, � <br /> Grout Inspection By Date n SPECIAL Well Permit <br /> Pump Inspection By� ate D WAIVER Received <br /> FCOSoil Boring Inspection By Date Constructed Well Depth ft <br /> M NTS <br /> O� 3'0 <br /> FPE SC Received Che Amount Dale Permit/ Invoice# Wall ID# <br /> Codes Info B Cash Remitted Service Request# <br /> 043-06 WELL!PUMP PERMIT <br /> F, <br /> 04R e <br />