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WELL-OPUMP PERO V <br /> SAN JOAQUIN COUNT(ENVIRONMENTAL 1-IEALT hl DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232 - (209)468-3420 <br /> NON-REFUNDABLE PERN(IiT CALL_ 209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS 53 m <br /> �D (/ M <br /> CIT;/QIP ����� �SZ� <br /> GROSS STREET ,J >4/Y- N PARCEL SIZE/ USE APPLICATION#k M <br /> Cn <br /> OWNER 1'1AME �i�../ /y //'�/(/ PHONE <br /> ODUNER:`.DDRESS �/ CITY/STATE/ZIP Z�x <br /> CONTRACTOR ©�JQ,�`�J /�//Y /�I//z Pd/S PHONE <br /> CONTRACTOR ADDRESS `-1 Lr� //!/� 0� �L CI I Y/STATEIZIP <br /> n <br /> SUBCONTRACTOR B'IIOi!E <br /> SUBCONTRACTOR ADDRESS CIrdSTATE/ZIP <br /> LICENSE C-57 -GI ❑ D-09 ❑ Other NUMBER ExPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range =iec ioii <br /> INTENDED USE ❑ Domestic/Private vi rigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Charact <br /> ❑ Public Water Sy ern <br /> If different from Owner: Water 6ysLem Name Contact ame or inone njurnoet <br /> TYPE OF-WORK 0(New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring #of borings . ins) ❑ Geotechnical 019 <br /> ❑ Qut-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair.tm�40,Vlew Pum ❑ Purn Re lacement ❑ Pum Re air ❑ Raise Well Casin �QOCO •7 <br /> Uc- -�fvZ 71Y <br /> WELL CONSTR TION - p��,MA( <br /> Drilling Method )JMud Rotary ❑Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other ENT <br /> Proposed Well Depth 30 ft Excavation in diameter ❑ Open Bottom ravel Pack/Gravel Size � � in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter� L in Thicl< Gauge/ASTM Sched Z ❑ Steel eNPlastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth_ SSL ftKP'Neat Cement(94 lb bag/5-10 gal wafer) ❑ Sand Cement sack nix/7 gal water <br /> Aptentonite(20%solids) ❑ Other <br /> Grout Placement Method Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contra ori ❑ Other <br /> ❑ Concrete Pedestal Dimensions:Width ength ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> Pump ubmersiblc❑ Turbine ❑ Other IIP Pump Set it `Mantling Water Level <br /> I HEREBY CERTIFY YHAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCE$, 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 /> M �C-IOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE��jlDAT-0-7 <br /> f <br /> AV <br /> DEPARTMENT USE ONLY 1� <br /> Application Accepted By Date `,�/ Area Employee[D# SK-- <br /> Grout Inspection By J Date PECIAL Well Permit <br /> Pump Inspection By MAU doo~ Date 0 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS Gymit 4 '1vtC�r'C <br /> PE SC ReceivedChe Amount PerrniU <br /> Codes Info By Cash Remitted ©ate Service Request;k Invoice# Well IDsi <br /> g1 <br /> 1® <br /> EH0 43.06 WELL/PUMP PERMIT <br /> 8104!08 <br />