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WELL 1 PUMP PERMIT :. <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH,_ ARTMENT 304 E WEBEti.._iE 3"°FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOBADDAESS � �z-✓ I_ f.- � ' � Ae.' !� 4"r`�1 /��a►4.-- � CITY/ZIP � <br /> CROSSSTREET APN ("(��`� 1 l' 1•,i—PARCEL SIZE . O LAND USE APPLICATION# �y <br /> 'Auk-) v <br /> ` T t PHONE <br /> OWNER NAME i <br /> OWNER ADDRESS L- <br /> CONTRACTOR 'W f i CITY/STATE/Z[P <br /> � � �!r[ r]i� t C PHONE 2_05_ei` % <br /> y,� <br /> CONTRACTOR ADDRESS L e- CITY/STATE/ZIP SAC_ <br /> PHONE <br /> SUBCONTRACTOR <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE L-0,C-57 ❑C-61 ❑D-09 ❑Other NUMBER G-J EXPIRATION DAT£ 1 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑Domestic/Private 13Irrigation/Agricultural 11Industrial ❑Water Quality Monitoring Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: ater System Name ontact ame or one Num er <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification CI Other <br /> N of borings Geotechnical ���#of borings <br /> 13 Monitoring Well(s) #of wells ❑Soil Boring(s) <br /> ❑Out-Of-Service Well ❑Out-Of-Service Weli Renewal ❑Cross-Connection Repair <br /> 0 New Pump ❑Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary *ger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth 5�—2-0 ft Excavation4(f) in diameter ❑Open Bottom ❑Gravel Pack 1 Gravel Size in diameter <br /> ❑Conductor Casing in diameter i Conductor Casing Depth ft �• <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel 0 Plastic ❑Stainless Steel ❑Other `+ <br /> Grout Seal Depth ft ❑Neat Cement(94 tb bag/5-l0 gat water) ❑Sand Cement sack mix 17 gal water !i� <br /> 13Bentonite(20%solids) ❑Manufacturer Spec%solids % Name Ha (6"el '-1_a` ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped 0 Free Fall ❑Other ❑Retardant/Accelerator(name) r' <br /> O <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. 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 /> INIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED Q <br /> TITLE T � 1 DATE <br /> aj <br /> qViRbrM <br /> M <br /> IPA T & <br /> L1. L1 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Area Employee ID# � <br /> Grout Inspection Dale Z 7 06 ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed Well Depth ® It <br /> COMMENTS <br /> E <br /> PE SC Received hec Amount Permit/ <br /> Codes Info B ash Remitted Date Service Request <br /> # Invoice# Well[D# <br /> O p <br /> l <br /> EHD 43-02-006 <br /> 1!27!20(15 WELL PUMP PERMIT <br /> �-,�_� <br />