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iI WPX-�1/ 7MP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DFPARTMEf <br /> 3114E WEBER AVE 3°°FL-STOCKTONI 021)468-3420 <br /> NON-REFUNDABLE PERMIT !< CALL 209 9��-/b97 FOR INSPECTIONS EXPIRES 1 YEAR FROM s.ATE ISSUED <br /> JOB ADDRESS !-5-18q I /k/jl <br /> C[TyIZIP pr C <br /> CROSS STREET APNO <br /> ��{{C��y �t +� M <br /> V NcJ�I "V L. SIZE <br /> NPARCEL L —LAND USE APPLICATIONS#}—,]y�y <br /> OWNER NAME -- r'7 �/�/ C..� rl�.+N IR.L. +]Yr PHONE ry <br /> OWNER ADDRESS { (i(/� / CITYISTATEIZIPco <br /> CONTRACTOR - <br /> PHONE <br /> CONTRACTOR ADDRESS CRCYISTATEJZ[P <br /> SUBCONTRACTOR <br /> PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/Zip <br /> LICENSE ❑C-57 ❑C-6t ❑D-09 ❑Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinate, X Y Township Range Section <br /> INTENDED❑SR ❑Domestic/Private ❑Irrigaiion/Agricultural ❑Industrial ❑Water Quality Monitoring <br /> 13 Soil SamplirsglCharacteriration <br /> ❑Public Water System �! <br /> Hdiffemal fmm Owner: ora system °me °lots Nume or rmow Number <br /> TYPE OR WORx ❑New Weil,,? ❑Replacement Welt 17 Well Alterad0n/M0dificati0n ❑Other <br /> ❑Monitoring Wel](s) #ofwells ❑Soil Boring(s) pof borings paf6oringic <br /> ❑Geotechnical <br /> XOut-Of=Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump D Pump R iacement ❑Pump Repair <br /> WELL CON RUCrI <br /> Drilling Method ❑Mud Rotary ❑Air Rotary; ❑Auger - ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ft Exuavatian in diameter ❑Open Bottom ❑Gravel Pack/Gravel Sim in diameter <br /> ❑Conductor Casing in diameter I Conductor Casing Depth ft <br /> Well Casing Diameter_in ThicknesS/GaugelASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seat Depth fl ❑Neat Cement(94 lb bag 15-70,g&water) ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%so;ids) E3 Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Placement Method ❑Pumped C]Free Fall E3 Other 11 Retardant/Accelerator(name) <br /> PEDESCAL loatall¢d By ❑Driller ❑Pump Contractor ❑ Other <br /> 0 Concrete Pedestal Dimensions:Width ft Length It Thick in ❑Christy Box ❑Stave Pipe <br /> PUMP ❑Submersible ❑Turbine 13 Other HE Pump Set R Standing Water Level ft <br /> I HEREBY CERTIFY THAT I 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. I ALSO CERTIFY THAT MY REQUIRED LICENSE 1S <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> � j MINIMtM MINIM24 HOUVIADVANCE NOTICE;RF¢UIRED FOR INSPECTIONS <br /> SIGNED I TITLE' V1p1 XrN / t•�/ <br /> DATE <br /> La <br /> D E R TM E N . .. ,,...�. .,,..., .,...�... ., .. <br /> T USE ON /Y <br /> Application Accepted By t If- Area Employee ID# <br /> Grout Inspection By �' Date ❑ SPECIAL Well Permit i <br /> Pump Inspection By Date 13 WAIVER Received <br /> Constructed Well Depth It <br /> COMMEN 12'.: <br /> 7,'y.� L <br /> PE SC Received �chAmount PermlUCodes Info B Remitted Date Involee WellID# <br /> Servleerm t # <br /> y WELL PUMP PERMIT <br />