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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DW,%RTMENT y v` yy y 4 304 E WEBERn S"FL-STOCKTON CA 95202 - (209)468-3420 <br /> l ; <br /> NON-REFUNDABLE PERMIT ti BALL 209 953-7697 FOR INSPECTIONS LXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ApRESS (] OAU A4 CITY/ <br /> 7IPf ( <br /> R <br /> Y <br /> CROSS STREET _ _ B APN 5' 3O — PARCEL SIZE p A <br /> OWNER NAME �J f> PHONE <br /> f OW �PNERADDRESS f�frU Ol0' 4/ /VC�l CITY/STATEIZIP <br /> CONTRACTOR r <br /> PHONE 2D'P-7�f�27 `1 <br /> CONTRACTOR ADDRESS tJ� CITY/STATE/ZIP . CII <br /> SUBCONTRACTOR v9 <br /> PHONE <br /> t SUBCONTRACTOR ADDRESS CITYISTATE/ZIP <br /> LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE. ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑$oil Sampling/Characterization ^�Ci <br /> Cl Public Water System <br /> lfdifferent from Owner: Water System Namcontact ame or oneum r <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other <br /> ❑Monitoring Well(s) number of wells number of boriny� f b <br /> number of El Soil Boring{s) ❑Geotechnical <br /> ❑Well Destruction 0Out-Of-Service Well ❑ ut-Of-Service Well Renewal <br /> ❑New Pum ❑Pum Replacement ❑Pum Repair Cross-Connection Re air ]� <br /> WELL CONSTRUCTION <br /> l Drilling Method ❑Mud Rotary Q Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other i <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing ' in diameter / Conductor Casing Depth - 11 <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel EI Other C9 <br /> Grout Seal Depth ft ❑Neat Cement(94 lh hug/5-10 gal water) ❑Sand Cement .tack/nix 17 gal water <br /> Cl Bentonite(201/o solids) El Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted -.-q <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 13 Other HP Pump Set ft Standing Water Level ft <br /> WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other <br /> s <br /> Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from ft to ft �-- <br /> Sealing Material ❑Neat Cement(941h hug/5-10 gal water) El Sand Cement sack mix/7 gal water ❑Bentonite Pellets <br /> ❑Bentonite(200K solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Placement Method ❑Pumped ❑Free Fall D Other <br /> ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad <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 /> F 1 I MU 24 HOUR ADVANCE NOTICE REQUIRED FOPLINSPEgl�NSIGNED TITLE 42z(!ty 9A"- DSATE44 <br /> V. <br /> ly <br /> A t SgiON <br /> FAL <br /> i <br /> i <br />