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1 <br /> WELL / PUMP PERMIT <br /> -'SAN JJ_OAAQQUIN COUNTY ENVIRONMENTAL HEALTIVOLPARTMENT 304 E WEBEk AVE 3"0 FL-STOCKTON CA 95202 - (209)468-3420 <br /> N(*�_-KEFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> l-.l!'tV ��� t-L�Y�f � CITY/ZIP f �-�ri � � H <br /> JOB ADDRESS r� <br /> 030•-G 1 � ,I�t�� C <br /> CROSS STREET APN 1 -C-W)-0 2- PARCEL SIZE LAND USE APPLICATION# M <br /> 1 10 •-0'2-0-t�#" ren <br /> h -c'2v 0 T <br /> OWNER NAME ��U�V l!.1---��-1 � 12-0 .,......._.,..._—. .. PHONE <br /> OWNER ADDRESS ,�•�} �^,� CITYI✓STTAT(EIZIP <br /> i I�• l=7 �U+st L-LJ t .J PHONE <br /> CONTRACTOR //�,�a <br /> CONTRACTOR ADDRESS, t] _ U c-W 3 CITY/STATE/ZIP <~5 ) <br /> 12 <br /> SUBCONTRACTOR V tl� A - kt6 . PHONE { <br /> SUBCONTRACTOR ADDRESS ! LEM CITYISTATEIZIP -]:-1 <br /> h1 <br /> LICENSE 57 ❑C-61 O D-09 Cl O[herNUMBER Q If EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑ Industrial ❑Water Quality Monitoring Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name Contact Name orPhone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other <br /> ❑Monitonng Well(s) #ofwe[Is Spil Boring(s)� Nofborings eotcchnical ofbormes <br /> ❑Well Destruction ❑Out-Of-Service Well IJOut-Of-Servicej�Well Renewal <br /> ❑New Pump ❑Pump Replacement ❑PumR Repair ❑Cross-Connection Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> rr <br /> Proposed Well Depth 15--.3 U ft Excavation _in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft r L- ,� <br />' Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless SteelOther <br /> Grout Seal Depth ft ❑Neat Cement(94 lh hag/5-10 gal water) ❑Sand Cement suck m �r V <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted U <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant!Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other <br /> ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set R Standing Water Level ft h <br /> 1 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS, <br /> MINIMUM 24 FLOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> fIf�-A:I-J • 3� fi <br /> SIGNED TITLE DATE_ <br /> E <br /> r <br /> r� <br /> f <br /> l c dry <br /> NIR N L A <br /> - -�- -- _.. DEPARTMENT USE ONLY <br /> tj C <br /> Application Accepted By #� ''�--�. Date ?� Area Employee[D# �� L <br /> 9� <br /> Grout Inspection By Date 11SPECIAL Well Permit <br /> PUMP Inspection By Date ❑ WAIVER Received <br /> -LIcsLmLoon Inspection B Date Constructed Well Depth ft <br /> COMMENTS � � �� /�6� t�. ZAIV-7kseq�-417D <br /> At-�/ J �L / Oi7�.�✓;t�:�.. r p7i /7UL�C �d G�7J�2/-� <br /> PE SC Received heckffl Amount Permit! <br /> Codes Info B ash emitted attee (Service Request 4 Invoice# 'Well[D# <br /> `(-3. 72-. 15^0 <br /> EHD 43-02-1706 WELL PUMP PERMIT <br /> 976104 <br />