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WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH 1.c.PARTMENT 304 E WEBER--VF 3NO FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209)953-76197 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS _��'7^ CITY/21P SCs day L 'f <br /> , <br /> q <br /> CROSS STREET T/L/.is - APi�,C �f(1Cr__=�ZPARCEL SIZE 17`l�j"i AND USE APPLICATION# <br /> T j <br /> OWNER NAME ! PHONE �: H <br /> OWNER AD / -G-7�L'lJ1i� �� CITYISTATEIZIP ,�5� U�� r� i <br /> 14 <br /> /f 1� Kms, <br /> CONTRACTOR PHON <br /> +r <br /> CONTRACTOR ADDRESS /J I J J`Clr _ _ CITY/STATE/ZIP 'IL <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATE/ZIP <br /> LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBS ExPiRA.TION <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USEDomestic/Private ❑lrrigationlAgricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owster. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑New Welleplacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other <br /> ❑Monitoring Well(s) #of wells QSoil Boring(s) #afborings 13 Geotechnical #of borings <br /> ❑Well Destruction ❑Out-Of-Service Well CI Out-Of-Service Well Renewal <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair <br /> WELL CONSTRUCTION <br /> Drilling Method AMud Rotarv! ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ft Excavation / - in diameter 13 Open Bottom gravel Pack 1 Gravel Size in diameter <br /> ❑Conductor Casing in diameter ! Conductor Casing Depth ft <br /> Well Casing Diameter 1!� in Thickness/Gauge/ASTM Sched ❑SteelPlastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth 0 ft ❑Neat Cement(94!h hag/5-10 gat water) ❑Sand Cement suck mix 1 7 gal water r. <br /> 0ientomte(200/6 solids) ❑Manufacturer Spec%solids % Name ❑Specs on File lI Specs Submitted <br /> Grout Placement Method mped M Free Fall ❑Other ❑Retardant 1 Accelerator(name) <br /> PEDESTAL Installed By ❑Driller f!rymp Contractor ❑Other <br /> ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove,Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft r <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN i <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS, I ALSO CERTIFY THAT MY REQUIRED LICENSE 1S <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 <br /> It- { <br /> SIGNED �L //(,GG r L _ TITLE -."I'l C-pet DATE <br /> E <br /> Id � <br /> IXT <br /> AN JO 4C11)INC UN <br /> i <br /> e <br /> 2t 4 <br /> DEPARTMENT SE ONLY \ <br /> ~ A 1 coo o <br /> Application Accepted By DateArea Employee ID#� <br /> Grout Inspection By Date_ 11 SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Destruction Inspection By Date Constructed Well Depth ft <br /> COMMENTS Ot- ) <br /> PE SC Received hec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B ash Remitted Service Re nest# <br /> LG- 0 3zs. q 26 V5 (l1J <br /> EFID 43.02-006 - - WELL PUMP PERMIT <br /> R16/04 <br />