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VELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPA �NT 304 E WEBER AVI FL-STOCKTON CA.95202 - (209)468-34ZD <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> rn <br /> J08ADDRESS �/ V 1 I Poo CITY/ZIP L � a <br /> C� �J J v <br /> CROSS STREET `` APN / -�" l PARCEL SIZE (I' LAND USE AP�PLIICATJOON# <br /> OWNER NAME lf) i PHONE <br /> OWNER ADDRESS © D CITYISTATE/ZIP U �� <br /> CONTRACTOR G-- PHON O 9 <br /> CONTRACTOR ADDRESS CiTYISTATFJZIPR 5 Un l ,5 tO <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STAT'-E7/ZIP <br /> LICENSE ElC-57 ❑C 61 ❑D 09 � <br /> Other — � NUMBER L ?2 EXPIRATION DATE 1 U(, ,nn <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township RAnge " Section W <br /> INTENDtD USE Q Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different From Owner: Witer System Name Comact Name or Phone Number <br /> t <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(g) #ofborings 0 Geotechnical #ofbonngs <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair " <br /> ❑New Pump ❑Pum Replacement kPum2ROir <br /> WELL CONSTRUCTION <br /> Drilling Method 13 Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other V <br /> Proposed Well Depth 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 in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑.Other <br /> Grout Seal Depth ft ❑Neat Cement(941A bag/S-IOgot water) ❑Sand Cement sack mix 17 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By Q Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Boz ❑Stove Pipe <br /> PUMP Submersible ❑Turbine ❑Other HP Pump Set t ft Standing Water Level L Z 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 IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COM EN TION. AWS. O <br /> _ INI M 2 UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS J / L� <br /> SIGNED TITLE /4 �' Yt� L'�ATE �/ 7/ <br /> Q <br /> 'l1 <br /> V Gi <br /> y al N MN N <br /> a . <br /> 1_ <br /> DEPARTMENT USE ONLY [J,. <br /> Application Accepted By �� t` ' — Date 1 �� 05 Area Employee ID# "'Up <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date Jr, - ❑ WAIVER Received' <br /> .r <br /> Constructed WlI Dfe th / FA ft <br /> COMMENTS <br /> PE SC ReceivedCheck# Amount Permit/ <br /> Codes Info B ash Remitted Date Service Request# Invoice# ' Well 1D# y ` <br /> q3.-7`7 ©SD <br /> y ' <br /> EHD 43-02.006 WELL PUS. v� <br /> 112712005 <br />