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11 I'll do <br /> WELL / PUMP PERMIT SCAj ffl <br /> SAN JG.'QUIN COUNTY ENVIRONMENTAL HEALTh*%WPARTMENT 304 E WEBEW 3"°FL-STOCKTON CA 9$ - (209)468-3420 <br /> NON-REFUNDABLE PERMIT �( CALL 209 953-7697 FOR INSPECTIONS (\''�.q}EX'PPIIRES I YEAR FROM DATE ISSUED <br /> VAJOB ADDRESS `v / �/�,�/�, CITY/ZIP J na- i® y <br /> CROSS STREET .�^APN 1AL —6 ek)-aARC/ELL SIZE LAND USE APPLICATION# <br /> OWNERNAMEa'n J UC' `at \ lc. PHONE y <br /> OWNER ADDRESS ,, CITY/STATE/ZIP <br /> � O5a �a <br /> CONTRACTOR ` PHONE'/- -!qk J—'6"'I L1 O - <br /> CONTRACTOR ADDRESS TY/STATE/ZIP I C i `53. <br /> GN O <br /> SUBCONTRACTOR ]J 1V V"�,\��/n\� r�Ir 5�- `[�/�Y�\]cJl `�1 \/p`�• �//� PNONE ,t�F�JJ(]���(��^�L/) C �j <br /> vW &r- IG S f& V Orl C4Y/STATE/ZIP�Q G--te r <br /> SUBCONTRACTOR ADDRESS / <br /> LICENSE -57 ❑C-61 ❑D-09 ❑Other NUMBER E%PIRATION DATE 31 a.e+a 9, <br /> Y p I� <br /> GEOGRAPHICAL INFORMATION: Coordinates X J 3(�Ur Q3 to•\qt� Y 1 a' y 5'7a` LU •Township Range SectionA. _ //N <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring oil Sampling/Characterization Cli([�i / <br /> ❑Public Water System <br /> Ifdif@,mtfrom Owner: Was.,S,w. ame U.nUzt Name., one um r <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boringq of borings <br /> Boring(s) Geotechnical 'of borings <br /> ❑Out-0f-Service Well ❑Out-0f-Service Well Renewal ❑Cross-Connection epair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rorarrryyy ❑Air Rotary k.uger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth - ft 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 2—ft ❑Neat Cement(941b bag/5-/0gal water) ❑Sand Cement sack mix/7 gal water <br /> Y.Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method 13 Pumped ❑Free Fall ❑Other h5Xt ❑Retardant/Accelerator(name) <br /> PEDESTAL I dktalied By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑ nerete Pedestal Dimensions:Width R Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑tIh4qkle ❑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 1 AM IN COMPLIANCE WITH ALL <br /> WORKE PENSATION LAWS <br /> UM 2 OUR ADVANCE NOTICE//jy��1QUIRED FOR INSPECTIONS (� a�fA.� <br /> SIGN v�/✓ TITLE \-.•7 DATE ? x ht 0 V <br /> DEPARTMENT USE ONLY <br /> Application Accepted By_ c� �JDate _3 / U Area Employee ID#i5aQ <br /> Grout Inspection By, 45✓�.-w-41�T Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed Well Depth It <br /> COMM TS -i-r <br /> P SC Received Chec AmountPermit/Codes Info B ash Remitted Date Service Re uest# Invoice# WeI11D# <br /> 4372, 601 = <br /> ERD 43-02-0061'�- " - 3`Z_ -e,-/ WELL PUMP PERMIT <br /> Iri'Il1005 <br />