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WELL / PUMP PERMIT <br /> SAN JOAQVIN COUNTY ENVIRONMENTAL HEALTH DEI' 'MENT 304 E WEBER A ��°FL-STOCKTON CA 95202 - (209)46&3420 <br /> NON-REFUNDABLE <br /> EEIPERMIT �{LL 209 953-7697 FOR INSPECTIONS Gy7C1'IRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS -f Z -2 L O ./,-'/ y <br /> CITY/ZIP �/ '�r/s-(' 9���� <br /> CROSS STREET APN017 2-10 —O PARCEL SIZE Zg �� ea <br /> OWNER NAME PHONE <br /> OWNERADDRESS ZI Z!>U 4U V�.� — 1 O �t1V (CITY ATIP wac,-C+ (Q <br /> CONTRACTOR i <br /> P Q <br /> CONTRACTOR ADDRESS CITY/STAT IP / �/�c� `� <br /> SUBCONTRACTOR -7 �/ d BONE Z N <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP r� <br /> LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE '11 <br /> GEOGRAPHICAL INFORMATION: Coordinates X 3010;3 1 y Township _ Range Section �1 <br /> INTENDED USE omestic/Private ❑Irrigatfon/Agneultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Charseterinnion <br /> ❑Public Water System <br /> Ifdilferent from Owner: Water ysremame omen oma or or¢ um r <br /> TYPE OF WORK ❑New Well ❑Replacement Well O Well Alteration/Modification 0 Test Hole ❑Other <br /> ❑Monitoring Well(s) numberofwells 13 Soil Boris s number of borings <br /> ❑Geotechnical number ofbminas jv\l <br /> BO <br /> ❑Well Destruction >(Out-Of-Service Well ❑Out-Of-Service Well Renewal <br /> ❑New Pump ❑Pump R lacement ❑Pump Repair ❑Cross-Connection Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Sin—in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth tt <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Schell ❑Steel ❑Plastic O Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(941b fag/5-10gal wafer) 17 Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method O Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other <br /> ❑Concrete Pedestal Dimensions: Width_ It Length_R Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ti Standing Water Level It <br /> WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑UncaSed ❑Other Well Diameter in Total Depth R Depth to Water it ❑Casing to be Perforated from ft to R <br /> Sealing Material ❑Nut Cement(94 th fag/5-10gal water) ❑Sand Cement sack mix/7 gal water I7 Bentonite Pellets <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted <br /> Placement Method ❑Pumped ❑Free Fall ❑Other <br /> ❑Complete with Mushroom Cap It below grade ❑Complete to Existing Surface Pad <br /> I 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. 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 /> MIN M 2 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE DATE — -6�— <br /> )A a mr: <br /> 'L H ALTr SE V!L b <br /> non r, <br /> E RTMENT O Y <br /> Application Accepted By - Date Y Area Hmployee <br />