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( )WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D_.__RTMENT 304 E WEBER 3fO FL-STOCKTON CA 9520- 2 ---(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATEjSSUEIa,, <br /> JOB ADDRESS lfar -Rd Z..�.O 1 � � � 1 ��'_.,... 9 <br /> 1 YIZIP <br /> CP <br /> CROSS STREET L '^��' ti.� APN O 0 PARCEL SIZE LAND USE APPLICATION# <br /> OWNER NAME T,r LA PWL O PHONE ` L <br /> OWNER ADDRESS -SXA'5, U. CITYISTATE/ZIP <br /> CONTRACTOR ,r}�&g Ie PHONE <br /> . Ij�` <br /> CONTRACTOR ADDRESS t11� CITY/STATE/ZIP L/L/ au s l�-� //'C4 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEIZIP <br /> LICENSE -57 ❑C-61 ❑D-09 ❑Other NUMBER < f� EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> IND USEDomestic/Private ❑Irrigation/Agricultural ❑industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK>@Pew Well ❑Replacement Well ❑Well Alteration/Modification ❑Other . <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) q of borings 13Geotechnical N of borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> O�RNew Pump ❑Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling MethodW:�Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth �" ft Excavation in diameter ❑Open Bottom Gravel Pack i Gravel Size in diameter <br /> ❑Conductor Casing in diameter 1 Conductor Casing Depth ft <br /> Well Casing Diameter 4–in.. Thickness/GaugelASTM Schad 'Lao ❑:Steel lastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth :3 20 ft ❑Neat Cement(941h bag/5-10 gal water) X1.$and Cement_lg sack mix 17 gal water <br /> ❑Bentonite(�_0%so—lids) 0 Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By Tiller ❑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 —ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION A D THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <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 1 AM IN COMPLIANCE WITH ALL , <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE I,JIl DATE 3 —L�4o� ,-L <br /> 7 <br /> I <br /> r <br /> F <br /> O � <br /> M T <br /> �T <br /> .,. __ ....... E RT.. ENT O LY <br /> Application Accepted B ate O Area' Employee ID.# <br /> Grout Inspection Das �� ❑ SPECIAL Well Permit <br /> Pump Inspection Date ❑ WAIVER Received <br /> Constructed Well Depth <br /> COMMENTS <br /> PE SC Receivedhec Amount Date Permit! Invoice# Well 1D# <br /> Codes Info By Cash Remitted Service Request# <br /> o GU 5 <br /> 3 �'v S P-00 q V, w?Oo;;L 7 a <br /> EHD 43-02-606 WELL PUMP PERMIT <br /> ]1272005 <br />