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WELL 1 PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE.06 FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> 1 r F <br /> Jon ADDRESS '�C' ,)'•� � 1+� Y�� "T I_ f'- aJ - Cn"Y/ZtP_ f�-C�r�-•"'f.��� `^ <br /> ' CROSS M-RELT ._-v rj r_- 7- 4-.-{el r �- C CF .SIZE LAND USFAPPLICATION <br /> - c # <br /> OWNER NAME /�I ri IZ' 1 r1 PITON 7 cam• K <br /> } OWNER ADDRESS / CITYISTATE/ZIP 4C-` r14 <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITYISTATEIZIP 17 <br /> SUBCONTRACTOR PHOC4AP-Nu <br /> SUBCONTRACTOR ADDRESS CITYISTATEIZIP <br /> LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE <br /> r <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural IJ Industrial ❑Water Quality Monitoring Q Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name Contact Name or P ono Number <br /> i TYPE OF WORK ❑New Well ❑Replacement Well ❑We]lAltcrationlModiftcation Other C -•`{t=•tiT 1�F-d� S"%7`tit- +i��-.�'4{- -A"-� �'.'� <br /> ❑Monitoring Well(s) #of wells EISoil Boring(s) #of .rings ❑Geotechnical a ofboringa <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Purn2 Replacement ❑Pump Repair <br /> i <br /> WELL CONSTRUCTION <br /> i Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack 1 Gravel Size in diameter L� <br /> r ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 lb bag/5-10 gat water) ❑Sand Cement sack mix 17 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> :Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant I Accelerator(name) <br /> PEDESTAL Installed By 0 Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe N <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION'AND THAT THE WORK WILL HE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS l) <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> 1 "WORKERS COMPENSATION LAWS. <br /> `� MINIMUM 24 "OUR ADVANCE NO'T'ICE RE-QUIRED FOR INSPECTIONS <br /> , 'SIGNED <br /> TITLE ./ 'l 5 DATE <br /> w _ <br /> -Ak XV <br /> i - <br /> �. <br /> —7- — - -- - --- - - <br /> J DEPARTMENT USE ONLY <br /> rr <br /> Application Accept d_ <br /> By �. 0/t^--� Date I C C Area Employee IDA -5 ,j �'r" <br /> a /// <br /> Grout[nspKtion By '+ Date 0 SPECIAL Well Permit <br /> I' ' ',' Date ,, r 0 WAIVER Received <br /> {. Pump[nsction-H�: "/c'i '" i:.�/ <br /> Constructed Well Depth f ft _--� <br /> COMMENTS �• - - <br /> �>' l"�'!,•. � .�'�"�'ter'; ��"_ice-`c,;a' <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# WellID# <br /> Codes Info By Cash Remitted Service Request# <br /> WELL.PUMP PI.RMiT <br /> 'Ent)43-02-006 <br /> 1,270005 <br />