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?j WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3-FL-STOCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 20 953-7697 FOR INSPECTIO\ti EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP y <br /> 1J,- O <br /> CROSS STREET 1 APN �t/- ��� �' YARCEL SIZE 1"y� LAND USE L CATION# <br /> OWNER NAME 1. PHONE lJ717 M111.' <br /> Ft. <br /> OWNER ADDRESS J CrrY/STATF/ZIP ^J �7 ./n^7 <br /> CONTRACTOR /L/ r. PHONED/ -- / /✓tJ`� <br /> CONTRACTOR ADDRESS r OLS L�� <br /> CITY/STATElZ1P <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ IP // <br /> LICENSE -57 13C-61 ❑D-09 Cl Other NUMBER EXPIRATION DATE G) <br /> GEOGRAPHICAL INFO ATION: 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 /> U dif t from Own Wmymm ame C..tact N—.r Ph.. a `1 <br /> TYPE OF WORKNew Well ❑Replacement Well ❑Well Alteration/Modification ❑Other N <br /> ❑Monitoring Well(s) #of wells ❑Soil BoringNDfborings Nofborings <br /> Boring(s) ❑Geotechnical ` <br /> ❑Out-Of--Service Well ❑Out-0f-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> f <br /> Drilling Method ud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point e0 Other <br /> Proposed Well Depth *:9jW ft Excavation /I in diameter ❑Open Bottom 2115mvel Pack/Gravel Sizer)e 16in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth —ft ' <br /> Well Casing Diameter_6_in Thickness/Gauge/ASTM Sched 210n ❑Steel [J'Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth 2W ft 1 ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix/7 galwater -� <br /> OKentonite(220/0%solids) ❑Manufacturer Spec%solids % Name�_�(/moi,L LIQ pees on File ❑Specs Submitted <br /> Grout Placement Method V<onped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller Erfump Contractor ❑ Other V <br /> ❑Concrete Pedestal Dimensions:Width R Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level 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. 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 /> MINI IUNI 24 HOUR ADVANCE NOTICE R UIRED FOR INSPECTIONS `7 <br /> SIGNED + TITLE DA131 <br /> / <br /> III a CA <br /> IJ <br /> p UI <br /> E RTMENT USE ONL "- - - - <br /> Application Accepted B Date_ Area Employee ID# ;C t� <br /> Grout Inspection B Date O ❑ SPECIAL Well Permit 1 <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed Well <br /> lDD,epth It <br /> COMMENTS /%L�(�s Sao A� �� f���SIIsX_ ✓K) IiSLI�fJ�' 1 �d <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B ash Remitted Service Request# <br /> f <br /> EHD 43-02-006 WELL PUMP PERMIT <br /> 1/772005 <br />