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"'4 WELL /TUMP PERMIT HEALTH WART �U4 E WEBER 7 E 3"FL-STOCKTON CA 95202 - (209)468-3420 l SAN JOAQUIN COUNTY ENVIRONMENTAL J NON-REFUNDABLE PERMIT CALL(2091953-7697 FOR INsPECTIONs EXPIRES 1 YEAR FROM DATE IttSS''UED CITYIZIP O JOB ADDRESS' OA �� p APNy ~f —()�'ZPARCEL SIZE ^LAND USE APPLICATION# q CROSS STREET PHONE OWNER NAME > e I, r CITYISTATEIZIP OWNERADDRFSS — ? r PHONE CONTRACTOR CITY/STATE/ZIP CONTRACTOR ADDRESS Itl PHONE SUBCONTRACTOR CITY/STATFJZIP SUBCONTRACTOR ADDRESS LICENSE ❑C-57 ❑C-61 ❑D-09 Cl Other NUMBER EXPIRATION DATE GEOGRAPHICALINFORMATION- Coordinates X Y Township Range Section IMNDED USE ❑Dorrestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization € ❑Public Water System If different from Omer: aterystem ame Contact Nam or one um TYPE OF WORK ❑New Welljv' ❑'Rcplacement Well ❑Well Alteration/Modification ❑Other " 0ofborings ❑Geotechnical #afboringb € ❑Monitoring Well(s) #of wells 13 Soil Boring(s) 1 XiOut-0f-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair ❑New Pump ❑Pump Replacement ❑Pump Repair WELL C014STRUC11ON ' h Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other �] ProposedlWell Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter `r\l ❑Conductor Casing in diameter / Conductor Casing Depth ft WeII Casing Diameter in Thickness/Gauge/ASTM Sched 13Steel 13Plastic ❑Stainless Steel ❑Other it Grout Seal Depth ft ❑Neat Cement(94 lb bag/3-10 gal water) ❑Sand Cement sack mix/7 gal water 4 ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method 13Pumped 13Free Fall ❑Other t ❑Retardant/Accelerator(name) lk.F=FAL�11! Installed By ❑Driller ❑Pump Contractor ❑ Other d; ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP 111": ❑Submersible ❑Turbine ❑Other HP Pump Set R Standing Water Level ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN-.COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL cam, WORKERS COMPENSATION LAWS. A i MIN M 24 HOURADVANCE NOTICE RLEOUIRED FOR INSPECTIONS SIGNED E�I TITLE 6A DATE fG 3 OIL t i j II iG. i. �r ; p; u !IfE { Application Accepted By. �� Area Employee ID# ^ y Grout InspectionB Date D SPECIAL Well Permit ` By I Pump inspection By Date^ 17 WAIVER Received Constructed Well Depth ft COMMENTLj � • - -� � PE SC Received Chc&#/ Amount Date Permit/ Invoice WellID# / Codes Info B ash Remitted Service Request# F � ERD 43-02-006 WELL PUMP PERMIT 1/2712005 ',,II, -- .