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WELL/ PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3-FL-STOCKTON CA 95202 - (209)46&342o <br /> NON-RF,FVNDABLE PERMIT CALL(2`09)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB AL'DRESS �CnZ a/� �. L) \` Qd\ CrrY/ZIP �I�✓1 � - T <br /> CROSS STREET IIL a APN 001-2-30-W �� � <br /> �, I' PARCEL SIZE LAND USE APPLICATION p <br /> ll'' n <br /> OWNER NAME ,S4C_ F"'C7�, .C-J r4c7'z d u.CT-S PHONE <br /> OW"NERADDRESs _ CITY/STATE/ZIP <br /> CONTRACTOR �I�J�' e Q�� L. �+PHONE <br /> 1,� f <br /> CONTIUCTORADDRESi _�L{4� _I- ` _ CITY/S`TATE/ZIP �11L1f1�.� CA gSZp-T <br /> SUBCONTRACTOR SQ4-) PHONE <br /> SUBCONTRACTOR ADDRESS CITY/S-1 ATFJ71 P <br /> LICENSE C-57 ❑C-61 0 D4)9 D Other NUMBER q6729z EXPIRATION DATe <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y _ Township Rxnge Section <br /> 7SE ❑Domestic/Private ❑Irriganon,'Agricultural ❑Induslnal ❑Water Quality Monitoring Soil Samphng/Charactcrization <br /> O Public Water System <br /> If different from O0.— aur.yxum in- _ Co.—> or um <br /> TvPE OF K'ORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole Cl Other <br /> ❑Monitoring Well(s) 9nfvvells ❑Soil Boring(s) _ sofbonnga Geotechnicalolosuf borings <br /> ❑Well Destruction D Out-OGService Well O Out-Of-Servta_Well Renewal <br /> ❑Ncw Pump D Pump Rc la;.ement D Pump Repair ❑Cross-Connrxiion Repair <br /> WELL CONSTRUCTION <br /> Drilling Method D Mud Rotary D Air Rotary Auger D Cable Tool D Push Point ❑Other <br /> r <br /> Proposed Well Ugpth�p'JSy fl h <br /> Excavation 4 _4 in diameter ❑Open Bottom ❑Gravel Pack/Grove]Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth fl �} <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched _ ❑Steel O Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 1h hag/S-l Ogal wwte,) ❑Sand Cement sack mix/7 gal water tr <br /> O Bentonite(20%solids) 0 Manufacturer Spec%solids _% Name�e i ❑Specs on File ❑Specs s SubmittedN <br /> I Grout Placement Method ❑Pumped ❑Free Fal l 11 Other_ ❑Retardant/iceelcrator(name) 0 <br /> PEDESTAL Installed By D(hiller ❑Pump Contractor D Other <br /> D Concrete Pedestal Dimensions: Width 9 Length fl Thick in ❑Christy Be. ❑Stove Pipe <br /> 7 <br /> PUMP ❑Submersihic O Turbine ❑Other HP__ Pump Set fl Standing Water Level <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN rh <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 ALL <br /> WORKERS COMPENSATION LAWS. <br /> 11NIMUM 24 HOUR ADVANCE.NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE RDATE io� oy <br /> TTTT <br /> 4tL <br /> t <br /> ISI I. <br /> I� i, <br /> N!_I l a'�"ssraa.soar. i <br /> DEPARTMENT USE ONLY <br /> Application Accepted By e` Dale D Area EmpLvee IDO <br /> Grout Inspection Bye Date ❑ SPECIAL Well Permit <br /> Pump Inspect' n By _ Date ❑ WAIVER Received <br /> Destruction Inspr/ y - Dale"a���� Constructed Well Depth It <br /> COMMENTS <br /> PE SC Received bee kp Amount Permit! <br /> Codes Info By ash Remitted ate Service Request N Invoice q Well IQs <br /> 437 (5c 0c;.ter <br />