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����VELL / PUMP PERMIT '�r!,�({, <br /> AIfT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPMENT 304 E WEBER AVF;�"D FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS r, L� 0 CITY/ZIP (-A i 1 C Q • I?T4 3 2— <br /> CROSS <br /> CROSS STREET ] rte' -s-LSJ✓ APN V PARCEL SIZE.'] ( LAND USE APPLICATION# Am <br /> _7-tmes � C�+ r3a�� 9 0733 <br /> OWNER NAME n ''7 /� PHONE `— <br /> OWNER ADDRESS /� 42,GOA Z /ZV CITY/STATE/ZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICALINPORMATION: Coordinates X Y Township _ Range Section <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public WaterSystem <br /> Kdifrerentfrom Owner Waftr System Nam Co.WtN..rPho.eNu.b., <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #ofbonngs ❑Geotechnical #ofbonngs <br /> A Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth R Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 1h bag/5-10 gal wafer) ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump 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 <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. 1 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 /> INI 124 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE D DATE ' ^/ r <br /> JO <br /> H G , > , <br /> DEPARTMENT U E ONLY <br /> e / [ <br /> Application Accepted By Date Area Employee <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump In tion By Date i'a��i�/�'S ❑ WAIVER Received <br /> Constructed th ft <br /> COMMENTS APIY& 1,'4iSvrCPAnSX/C99) <br /> PE SC Received hecldl/ Amount Date Peeraw Invoice Wel D# <br /> Codes Info By I ash Remitted Service Re uesl# <br /> 3 0 on a.57 <br /> END 43-02-006 P...�-�ITe <br /> IR7R005 <br />