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--�--� WELL / PUMP PERMIT / j' <br /> _ SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTM41EPARTMENT 304 E WEBEw AVE 3""FL-STOCKTON CA 9526 '468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES�I YEAR FROM DATE ISSUED <br /> JOB ADDRESS v C c� W CITY/ZIPG q <br /> CROSS STREET �/�" ' APN PARCEL SIZE LZJ- t t z <br /> N <br /> OWNER NAME PIIONE7y7- 3 `� 7-5 y <br /> OWNER ADDRESS / r/_� c /// / CITY/SI'ATE/ZIP <br /> CONTRACTOR Y � ��J�O/�"�n( `�v` ' / PPIIO�NE 33 <br /> CONTRACTOR ADDRESS 4J V ( l;J CS' CITY/STATEJZIP L� 4 <br /> SUBCONTRACTOR PHONE <br /> _ SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE >51Z-57 ❑C-61 ❑D-09 ❑Other NUMBER'3-273 S EXPIRATION DATE �_t <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ` pmestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization n <br /> ❑Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE Or WORK>6New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other <br /> number of wells number of borings number of borings <br /> ❑Monitoring Well(s) ❑Soil Boring(s) ❑Geotechnical <br /> ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal <br /> _ ew <br /> Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair <br /> WELL CONSTRUCTION ` <br /> Drilling MethodX_Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth7 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 -4G- in Thickness/Gauge/ASTM Sched ❑Steel -"ErPlastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ate ft ❑Neat Cement(94 lb hug/5-10 gal water) 'Sand Cement / suck mir/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name -❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ,'XKumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By -If-'Driller ❑Pump Contractor p� ❑Other <br /> ❑Concrete Pedestal Dimensions: Width ft Length y ft Thick_� in ❑Christy Box ❑Stove Pipe <br /> PUMP bmersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other <br /> Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from ft to ft <br /> Sealing Material ❑Neat Cement(94 lb bag/5-10 gal wafer) ❑Sand Cement suck mix/7 gal water ❑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 ft 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MIN 1UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS f 7," `�/�- `-� �/ <br /> SIGNED l� TITLE DATE <br /> - l <br /> 7 ! ss <br /> l <br /> n <br /> J <br /> A' lu <br /> TF1 iMSIOM <br /> lr <br />