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. ,LL 1 PUMP PERMIT <br /> JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAK!Tr.NT 304 E WEBER Ave STOCKTON CA 95202 - (209)468-3420 <br /> JN-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS rXPIRES 1 YEAR FROM DATE ISSUED <br /> Chi! it <br /> (,1 .� e1124.0 C, •r V' CITYIZIP > <br /> JOB ADDRESS G V <br /> :J v <br /> CROSS STREET ITC yr APN �� `" I PARCEL SIZE. LAND USE APPLICATION# m <br /> w <br /> OWNER NAME )Z _ PHONE <br /> OWNER ADDRESS 0I CITY/STATE/ZIP '(� <br /> CONTRACTOR T C• PHONE /J�5•_►►7 <br /> CONTRACTOR ADDRESS 0 SL��t IL _ CITYISTATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATE/ZIP <br /> LICENSE ❑C-57 4C-61 ❑D-09 ❑Other 11�'�` h u�tBEIt Q�t� EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE I LDomestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner', Water System Name ontact arae or one Number <br /> TYPE OF WORK XNew Well ❑Replacement Weil ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(S) #of wells ❑Soil Boring(s) n ofhorings ❑Geotechnical a of borings <br /> ❑Out-Of-Service Well ❑Out-Of-Seryice Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION �- <br /> Drilling Method F Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom C]Gravel Pack/Gravel Size in diameter i <br /> ❑Conductor Casing 4; 'W in diameter / Conductor Casing Depth 1-7L') <br /> ft <br /> Well Casing Diameter & in Thickness/Gauge/ASTM Sched ❑Steel gPlastic ❑Stainless Steel ❑Other (j1 <br /> Grout Seal Depth /661 ft ❑Neat Cement(94 1h Aug 15-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> 3entonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) e' <br /> PEDF,STAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ubmersible ❑Turbine ❑Other HP _ Pump Set ' ft Standing Water Level'! S ft <br /> 1 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 /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED s ' 4'jz'j 'j TITLE - DATE <br /> tJ NK Vr !N O <br /> c <br /> DEPARTMENT U SE ONLY <br /> :� i <br />