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F1SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH i "RTMENT Y v+ `+ y yy4 304 E WEBS 3""FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 2119 9533--7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> F, JOB ADDRESS C[TYIZIP� ! y <br /> CROSS STREET e j g APN 1005 —0 30 — O , PARCEL SIZE V <br /> OWNER NAME PHONE <br /> OWNERADDRESS /� r �/ !/1 y •� CITYISTATEIZIP -,40—f� rj <br /> E CONTRACTOR PHONE <br /> t <br /> CONTRACTOR ADDRESS 2W66F CITYJSTATEIZIP <br /> SUBCONTRACTOR PHONE <br /> E <br /> SUBCONTRACTOR ADDRESS CITYISTATEIZIP <br /> F# I <br /> LICENSE Cl C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE <br /> r <br /> I f GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water.System <br /> If different from weer: ater ystem ame ontacl ame or Phone Number <br /> :. TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other <br /> 13 Monitoring Well(s) number ofwekls ❑Soil Boring(s) number ofbarin6s ❑Geotechnical numbrrofborinyn <br /> C <br /> ❑Well Destruction ❑Out-Of-Service Well ❑ ut-Of-Service Well Ren <br /> ewal <br /> f. - <br /> ❑New Pump Pump Replacement ❑Pump Repair ros-Conection Repair <br /> 3:WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary 0 Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter 'z <br /> D Conductor Casing in diameter 1 Conductor Casing Depth it 11 <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel M Plastic' la Stainless Steel ❑Other C <br /> Grout Seal Depth ft ❑Neat Cement(941h hug/S-ldgal water) ❑Sand Cement suck rnix 17 gal water <br /> ❑Bentonite(20°/a solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted —y <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant I Accelerator(name) <br /> PEDESTAL Installed By ❑Driller 11 Pump Contractor ❑Other <br /> ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe I' <br /> Pump ❑Submersible ❑Turbine C1 Other HP Pump Set ft Standing Water Level 11 <br /> WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other <br /> Well Diameter in Total Depth tl Depth to Water ft ❑Casing to be Perforated from ft to ft (^ <br /> Sealing Material ❑Neat Cement(941h bag/S-1Ogal water) ❑Sand Cement sack in&17 gal water ❑Bentonite Pellets <br /> ❑Bentonite(20°/a solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Placement Method ❑Pumped ❑Free Fall ❑Other <br /> F4 ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad <br /> f 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 RECULATIONS— I 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 /> WORKERS COMPENSATION LAWS. <br /> 24 HOUR ADVANCE NOTICE ®�IN�SPrE Tf�NS' �+ <br /> SIGNED TITLE ��,�„' �d�o DATE �c3 QL <br /> Y <br />€ as <br /> FJ � <br /> ly v n <br /> f v <br />