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WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONNIENTAI,HEALTH DE ti1ENT 304 E WEBER A40""N"°EL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT / (-ALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS /W f d CITY!"L[P Ze6 ei 7 /� � <br /> - � t�'+ <br /> /� a <br /> CROSS STREET LC_ r AP N G� !f [..' CT/ ARCEL S12.E/_-,LAND USE APPLtCAT1ON 4 <br /> FL <br /> OWNER NAMEPH <br /> / ! ;Q <br /> I �O{N C/ <br /> OWNER ADDRESS / I Q �J ��-/ CITY/STATEIZIPCA f4 <br /> CONTRACTOR IONF' D� <br /> CONTRACTOR ADURESSr /5 / y /CETI'!$'TATF:/ZIP C� G,�3CU�C/ <br /> SUBCONTRACTOR $ IONS <br /> SLiBCONTRACTOR ADDRESS �CIi 1.#11ATEIZIP <br /> LICENSE ❑C-57 ❑C-61 ❑D-04 vollier NUAI6F:R � � EXPIRATION DATE Ql D <br /> GF.OGRAPHICALINFORntATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quahty Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water Syystem <br /> If diDtrem from Mer. ater System Nime Contact-Name orPhone Nom er <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other <br /> ❑Monitoring Well(s) #ofwells ❑Soil Boring(s) 0 o horings ❑Geotechnical lof borings <br /> ❑Well Destruction ❑Out-Ot=Service Well ❑Out-Of-Service Well Renewal <br /> New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Toot ❑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 Sea[ Depth Il ❑Neat Cement(94/h hug/S-10 gal wager) ❑Sand Cement suckmix/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fail El Other ❑ Retardant/Accelerator(name) <br /> PEDF.STAI, Installed By ❑Driller ❑Pump Contractor ❑Other <br /> ❑Concrete Pedestal Dimensions: Width 11 Length ti Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP Submersible ❑Turbine ❑Other HP_L_ Pump Set 11 Standing Water Level rt <br /> HEREBY CERTIFY THAT 1 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 ALI, <br /> WORKERS COMPENSATION LAWS. <br /> - MiNll� ifi/17 24 HOUR DVANCE NOTICE Q ED FOR SPECTIONS _ <br /> SIGNED/ i TITLE / ""/I ATE UI JV w <br /> } <br /> 6 3 <br /> I <br /> 1 <br /> .I Ao IIN c LITY <br /> - •D -I", =R- =M-E-N TiTw-.U-S-E _.O-N_L.Y <br /> Application Accepted By i date 7 '� Area ::91- Employee ID# / <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date 3 ❑ WAIVER Received / <br /> Destruction Inspecti 8 Date Constructed Well Depth ft <br /> COMMENTS — 01 62 ' <br /> PE SC ReceivedheM/ Amount Date Permit/ Invoice q Well 1Df1 <br /> Codes Info B as Remitted Service Request# <br /> D D4 LO <br /> AD <br /> EHD 45-02-006 W FLt.PUMP PERMIT <br /> XIW04 <br /> �ti <br />